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THE 

GYNECOLOGY  OF  OBSTETRICS 

AN  EXPOSITION  OF 

THE  PATFIOLOGIES  BEARING  DIRECTLY 

ON  PARTURITION 

BY 

DAVID  HADDEN 

B.S.,M.D. 

FELLOW  OF  THE  AMERICAN  ASSOCIATION  OF 
OBSTETRICIANS  AND  GYNECOLOGISTS 
FELLOW  OF  THE  AMERICAN  COL- 
LEGE OF  SURGEONS 


NEW  YORK 

THE  MACMILLAN  COMPANY 

1915 


Copyright  April,  1915 

by 

DAVID  HADDEN 

Oakland,  Cal. 


San  Fraincisco: 

Taylor,  Nash  &  Taylor 

Printers 


TO  MY  UNCLE 
WILLIAM  KINGSTON  VICKERY 

WITH  WHOSE  AID  AND 

COUNSEL  THE  FOUNDATION  WAS  LAID 

THAT  MADE  THE  WORK  POSSIBLE 

I  GRATEFULLY  DEDICATE 

THIS  BOOK 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/gynecologyofobstOOhadd 


FOREWORD 

The  iiHijori///  of  the  jxilioils  irlio  conic  to  the  (j//)icco/<f(jisf 
for  (idi'icc  suffer  from  flic  effecis  of  injuries  sustnined  dnrinfj 
liihor.  Often  the  (letiuif  jxifhotof/tf  in  rot  red  liiis  not  tx-en  recog- 
nized, or,  if  recofpnzed ,  /his  t)een  underestinidted  t>/j  tlie  fjen- 
eriil  j)r(ict itioner.  \ot  inf re(]iientt ij  t/ie  jxdient  Inis  fwen  nd- 
rised,  nnd  tlint  eren  Ij/j  men  tr/iose  experience  shoidd  dictate 
otJieririse,  to  ii'iiit  until  the  child-l)earinc)  ])eriod  /.<?  over  before 
sii/tniittinf/  to  ojx'rotire  repair. 

Xo  fotid  outcome  is  to  he  expected  fro)n  the  lacerated  cervix 
or  the  relaxed  vafjinal  outlet,  hut  tliene  conditions  may  not  only 
/ircroit  the  desired  increase  of  familij  hij  sterilitij  or  niiscar- 
riai/c,  hut  may  conijH'l  the  individual  to  drag  out  an  existence 
of  ill -health. 

From  the  surtjical  standpoint  the  lacerated  cervix  and  the 
relaxed  vaginal  outlet  are  considered  minor  procedures ;  hut 
from  the  standpoint  of  the  woman's  weU-heing  they  are  of 
major  imj)orta)ice.  These  minor  operations  are  often  lost  sight 
of  i)i  the  desire  to  do  tlie  more  spectacular  major  work,  when 
frequently  the  condition  requiring  ahdominal  operation  is 
the  result  of  the  injuries.  Abdominal  work  is  often  simpler 
and  easier  of  acco)nplis]nnent  than  the  repairing  of  vaginal 
injuries. 

Price,  of  Philadedphia,  always  held  that  the  skill  required 
for  the  proper  performance  of  correct  plastic  work  should  he 
developed  by  men  specicdizing  therein.  Sucli  tvas  his  opinion 
of  the  less  spectacular  minor  surgery  of  gynecology. 

A  desire  to  he  able  to  present  to  the  students  under  )ny  i)i- 
struction  a  more  graphic  and  detailed  account  of  the  structures 
of  tlie  female  }>elvis  and  outlet  than  I  was  able  to  gather  from 


vi  THE  GYNECOLOGY  OF  OBSTETRICS 

text-hoohs  led  me,  when  the  opportunity  of  obtaining  normal 
material  presented  itself,  to  take  up  a  care  fid  anatomical 
study. 

I  soon  realised  that  there  was  no  conformity  hettveen  the 
actual  findings  and  the  text-hook  descriptions.  The -recognized 
anatomies  deal  very  superficially  with  the  female  pelvis,  and 
the  gynecologies,  as  a  rule,  copy  those  authorities. 

I  hoped  hy  this  study  as  well  to  find  some  reason  for  the 
generally  poor  understanding  hy  the  physician  of  the  relaxed 
vaginal  outlet  and  the  often  unsatisfactory  immediate  and 
secondary  repair.  The  residt  is  that  I  have  written  the  chap- 
ter on  anatomy  wholly  from  my  dissecting-room  findings,  with 
the  main  emphasis  on  the  points  that  most  interest  the  surgeon. 

The  minutiae  of  muscle-fiber  distribution  and  details  of  no 
moment  to  the  accurate  surgical  correction  of  injuries  have 
been  omitted.  This  I  have  done  with  the  hope  of  being  able  to 
present  a  vivid  mental  picture  of  the  important  relations  that 
the  operator  must  have  while  doing  perineorrha'phies  and  other 
plastic  work. 

For  the  opportunities  to  prosecute  this  dissection  work,  I 
desire  to  express  my  appreciation  to  Dr.  R.  O.  Moody,  Asso- 
ciate Professor  of  Anatomy  at  the  University  of  California. 

The  anatomical  study  naturally  carried  me  into  the  details 
of  histology,  and  thence  to  the  pathological  findings,  for  I  felt 
that  the  average  gynecology  did  not  contain  a  sufficiently  com- 
plete series  of  illustrations  to  avoid  the  necessity  of  reference 
to  histology  and  pathology  text-books,  which,  as  a  rule,  give 
only  a  small  space  to  the  gynecological  field. 

The  illustrations  are  all  original,  from  specimens  selected 
to  represent  as  typical  a  series  as  possible,  and  the  micro  phot  o- 
graphs  represent  the  main  diagnostic  points.  For  some  of  the 
slides  from  which  these  photographic  reproductions  are  made 


FOREWORD  vii 

/  (]('sirc  lo  llidiih-  Dr.  Liid/cifj  l^icli,  of  Ijri-h'ii,  iriili  irlioni  I  IkkJ 
llic  /)/((is/irc  of  hihi ufi  II j)  some  of  titis  ivork. 

The  inmloiniriil  fniiliiu/s,  T  found,  were  poorly  port  rayed 
by  hliicl>-iiti(l-irliilc  phi f is,  so  color  pliofoyraphy  tvas  resorted 
lo.  A II Hi II  (lips  lo  color  (lie  slracliircs  lo  be  empliasized  were 
used  lo  (jcf  llie  required  contrast.  These  color  jdolcs  yive 
niiicli  (jrcalcr  (lcj)Ui  of  focus  irilli  better  coiilnisl  tliaii  ordiiiury 
phot  Of]  rii  plis. 

Tlic  ini possibilil y  of  ciihirf/iny  sucli  jdates  in  reproduction 
lias  necessitated  llic  present  size,  though,  I  realize  larger  illus- 
t ra lions  could  be  more  easily  studied.  For  the  great  interest 
mid  care  taken  in  the  reproduction  of  these  color  photographs, 
as  irell  as  in  the  production  of  the  200-mesh  half-tones,  I  ivish 
to  express  my  appreciation  to  Mr.  E.  F.  Russ  and  his  tvorkers 
of  the  Sierra  Art  and  Engraving  Company. 

In  addition,  I  have  taken  up  a  comparative  study  of  the 
accepted  operative  procedures  of  plastic  work,  discussing  them 
irilh  the  data  obtained  in  the  dissecting-room  as  a  foundation. 

I  have  eliminated  as  far  as  possible  the  present  tendency  to 
discuss  gynecological  operations  under  a  nomenclature  of  sur- 
geons' names.  While  it  is  only  just  to  give  credit  to  amj  indi- 
vidual who  introduces  a  worthy  surgical  procedure,  the  desire 
of  many  to  obtain  credit  for  an  operation  which  adds  a  modi- 
fication of  only  slight  variation  that  in  no  tvay  changes  the 
principles  involved  must  be  confusing.  To  the  student  such 
individualization  makes  the  average  text-book  of  gynecology 
merely  a  mass  of  operations  from  which  he  }nay  have  difficulty 
in  gathering  the  correct  principles,  so  that  he  gets  no  appre- 
ciation, or  at  best  a  poor  one,  of  the  real  factors  at  fault  and 
to  be  corrected. 

I  have  no  new  operations  of  my  own  to  discuss.  I  may  have 
taken  away  credit  due  to  some  one;  but,  if  so,  it  has  only  been 


viii  THE  GYNECOLOGY  OF  OBSTETEICS 

because  I  have  attempted  to  take  up  tins  narrow  hut  important 
section  of  gynecology  and  discuss  it  from  the  basis  laid  down 
iii  the  cliapters  on  anatomy  and  the  mechanics  of  pelvic  defects. 
If  the  effort  put  into  this  monograph  tvill  emphasize  the 
greater  importance  that  the  correct  trachelorrhaphy  and  peri- 
neorrhaphy have  to  the  physical  and  mentcd  well-heing  of  the 
mothers,  I  shall  consider  the  time  well  spent  and  shall  offer 
no  apology  for  adding  to  the  already  voluminous  medical 
literature. 


TABLE  OF  CONTENTS 

PAGE 

A^■A'^()M^•  Di' •iiii:  ( 'i:k\ix  AM)  I'KiJiXKr.M 1 

MkCIIAXICS   ol-    IIIK    liKI.AXKl)   Ol'TM"!' 22 

Etiologv  and  I*ki:\i:n'i'|i)n  of  IjAckka'I'ions 81 

PATIIOLOfn'  OK  Tin:  ( 'kkvix 40 

JSV.Ml'TO.MS  OK  CkKXICAI.    I'aI' I  Io|  .0(;N 66 

ThKAT.MKNT    ok   ('KKVICAI,    rATIIOLOGY 69 

Immediate  Hetairs .  74 

Curettage 83 

Cervix  Operations 90 

Symptoms  and  Diagnosis  of  the  Relaxed  Vaginal  Outlet     ...  97 

Perineorrhaphy 105 

Cystocele 121 

Correction  of  Cystocele 127 

Post-Operative  Treatment 134 

Prognosis  and  Post-Operative  Complications 141 

]\[iscarriage  and  Sterility 152 

Bladder  Infections 162 

Kidney  Ptosis 181 

Index 189 


ILLUSTRATIONS  IN  COLORS 

Ol'l'OSlTK 
PA(JE 

1*1, ATK  I.    A  iii('(li;iii  scclioii  through  the  female  pelvis  a1  llic  syiiipliNsis 

|)iil>is.  The  pelvic  organs  are  in  normal  relation 10 

I'latk  11.  A  median  section  ttironuli  tlie  female  pelvis  at  1  Ik;  symphysis 
pubis.  The  ulei'us  displaced,  in  oi'der  to  show  1he  relalion  of  the 
ureter  to  the  uterus  and  bladder 10 

I'l.vteIII.   Segment   of  the   levator-ani    musc](^   rutniinii'  between   the 

vauina  and  the  rectum 14 

Plate  IV.  The  pelvic  diaphragm  and  the  attachment  of  the  levator- 
ani  muscle  to  the  side  of  the  vagina 14 

Plate  V.  The  muscles  of  the  pelvic  floor 18 

Plate  VI.  The  gland  of  Bartholin.  The  bulb  of  the  vestibule     ...       18 

Plate  VII.  The  ischiorectal  fossae 20 

Plate  VIII.  The  muscles  of  the  vaginal  outlet  dissected  to  show  their 
relation  to  the  vaginal  outlet,  with  reference  to  episiotomy  in- 
cisions  32 

Plate  IX.  Dissection  of  a  relaxed  vaginal  outlet  to  show  the  retraction 

of  the  levator-ani  muscle 104 

Plate  X.  ]Main  nniscle  structures  of  the  pelvic  floor 112 

Plate  XI.  Blending  of  the  levator-ani  muscle  with  the  muscles  of  the 

floor  at  the  central  tendon 114 

Plate  XII.  Portion  of  the  levator-ani  muscle  between  the  vagina  and 

the  rectum 116 

Pate  XIII.  Shows  the  individual  middle  segment  of  the  levator-ani 

muscle 116 

Plate  XIV.  The  ventral  segment  of  the  levator-ani  nniscle  ....      124 


ILLUSTRATIONS  IN  BLACK  AND  WHITE 

PAf;E 

Hi'osinii  (if  ('('fvix (i7 

Lacci'iit  ioii  (iF  (*('i-\'i.\       .      .' 'M 

L;i('('i';i1  iiiiiot' cci-vix IJl 

('(M'vical  pol.xp 85 

X(inii;il  N'ii'Liiii  \iil\;i 20 

Hcliixcd  v;miii;il  out  let  ill  which  IK)  siipcfficinl  tear  oec'un'ed     ....  35 

Relaxed  vaniiial  outlet,  ceatral  teiidou  intact 36 

Kelaxetl  ()utl(4  with  central  tendon  onl>"  slightly  injured 115 

Perineorrhaphy  with  poor  diaphragm  support 98 

J*erineorrhaphy  with  poor  diaphragm  support,  defect  shoAvn  npoji  sepa- 
rating labia 99 

Perineorrhaphy  with  poor  diaphragm  support 109 

J'erineorrhaphy  witli  poor  diaphragm  support,  demonstrating  degree  of 

relaxation 110 

^Method  of  demonstrating  relaxed,  outlet  by  finger  ill  vagina      ....  100 

^Method  of  demonstrating  relaxed  outlet  by  pressure  from  above    .      .      .  101 

Outline  of  Ilegar  perineorrhaphy-  denudation Ill 

Perineorrhaphy  with  Somers  suture 118 

Graves's  cystocele  operation 130 

Temperature  curve,  sho^^'ing  effect  of  retention,  the  result  of  retrodis- 

placement  following  plastic  work  on  cervix 148 

Temperature  curve,  the  result  of  retention  following  cervix  amputation  149 


MICROPHOTOGRAPHS  IN  BLACK  AND  WHITE 

Normal  Structures 

Cross-section  of  normal  cervix 2 

Stratified  scpiamous  epithelium  of  cervix 4 

^lucous  memlirane  of  cervical  canal 4 

Epithelial  layer  of  mucous  membrane  of  cervix 5 

Higher  magnification  of  same  specimen 6 


xiv  THE  GYNECOLOGY  OF  OBSTETRICS 

Inflammatory  Processes 

Cross-section  of  cervical  glands 5 

Eroded  cervix .  61 

Eroded  cervix,  showing  cystic  glands 62 

Eroded  cervix,  showing  cystic  glands 64 

Eroded  cervix — an  acnte  process 63 

Eroded  cervix  in  healing  process .65 

Higher  magnification  of  same  specimen 65 

Cystic  endometrinm         7 

Cystic  endometrinm         8 

Polyp  of  cervix,  early  stage 86 

Polj^p  of  cervix,  with  cyst  formation 86 

Cervical  polyp,  showing  gland  proliferation 87 

Higher  magnification  of  polyp,  showing  gland  structnre       ...  87 

Tuberculosis  of  cervix 41 

Higher  magnification  of  same  specimen 42 

Decidual  wandering  cells  in  uterine  scrapings 83 

Higher  magnification  of  same  specimen 84 

Inflammatory  endometritis  simulating  malignancy 88 

Higher  magnification  of  same  specimen 89 

Malignant  Processes 

Carcinoma  beneath  mucous  membrane  of  cervix 53 

Carcinoma  beneath  mucous  membrane  of  cervix 54 

Carcinoma  of  cervix 49 

Carcinoma  nodule  in  deeper  tissue .55 

Carcinomatous  involvement  of  cervical  gland 46 

Extensive  carcinomatous  involvement  of  cervix 46 

Type  of  adenocarcinoma  comparatively  rare  in  cervix    .      .    •  .      .47 

Higher  magnification  of  the  same  specimen 48 

Metastatic  carcinomatous  involvement  of  lymph  gland    ....  50 

Chorioepithelioma  of  cervix 58 

Chorioepithelioma  of  cervix 59 

Higher  magnification  of  same  specimen 60 

Metastatic  chorioepithelioma  on  omentum 58 

Higher  magnification  of  sajue  specimen 58 


MICROPIIOTOdlJAPIIS  XV 

.Maij(;.\.\.\"i'  I'kocesses — ( 'oiil  iiiiuMl 

Kpithclioiiia  ()F  cervix 43 

Epitlu'lioina  of  ccr-vix 44 

Epitliclioina  of  ('(M-vix HI 

I  liylici- iiumiiifical  ion  of  same  s|)('('iin('n oi* 

Section  of  cpil liciioiiia.'sliowiim' "  jx'arls '' 4.") 

Section  sliowiiiii  polyinorplioiis  cliafartcr  of  inaliunani  cells        .       .  45 

Fibro.sarc<)nia  of  cervix 5t) 

Higher  iiumnifical  i(tn  of  same  s[)eciineii 57 


ANATOMY  OF  THE  CERVIX  AND  PERINEUM 

Wlll^iX  we  coiisidci-  llic  rciiialc  ix'lvic  slnicliii-c  and  oi-- 
^niis  ill  the  li,i;iit  of  the  I'uiictions  I'oi-  wliicli  tlioy  are 
(losigiie(l,the  wonder  is  tliat  any  woman  can  i^o  tliroiif^'h 
tlie  pliysi()l()i>ic'al  ordeal  of  cliildhirtli  without  liaving 
some  untowai'd  effects.  The  utei-us,  which  in  its  state  of  rest  is  nou 
lar,<>(M-  than  the  indivichial 's  fist,  must  increase  in  size  and  capacity 
sufhcicntly  to  retain  a  full-term  child  as  well  as  reserve  energy 
enough,  in  sjjite  of  its  excessive  distention,  to  expel  the  contents. 
The  birth  canal  nmst  so  change  its  character  as  to  accommodate  a 
body  many  times  the  size  of  its  caliber  at  rest,  and  yet  not  interfere 
too  greatly  with-  the  adjacent  structures  through  and  along  which 
the  canal  lies.  These  adjacent  structures  have  of  themselves  im]oor- 
tant  duties  to  accomplish  that  require  varying  degrees  of  area. 

The  structure  of  the  female- pelvis  is  designed  to  permit  of  ex- 
treme distention  of  its  contained  canals  without  sustaining  injury 
under  normal  conditions.  In  conditions  varying  from  the  normal, 
some  of  the  structures,  on  account  of  the  nature  of  their  location 
and  character  of  their  duties,  are  more  subject  to  strain;  conse- 
quently, the  abnormal  status  does  not  have  to  be  marked  to  accom- 
plish some  injury.  While  nature  in  all  cases  does  its  best  to  rem- 
edy any  resulting  defect,  nature  undirected  often  fails,  especially 
when  handicapped  by  mechanical  interference  or  infections. 

The  modern  life  of  woman  tends  to  cr-owd  her  mental  culture  at 
the  expense  of  physical  development  during  the  period  of  puberty. 
This  is  associated  with  a  type  of  dress  that  insufficiently  protects 
the  extremities  and  upper  trunk,  with  a  consequent  exaggeration 
of  the  venous  blood  supply  in  the  pelvis.  These  factors  favor  the 
occurrence  of  abnormalities  before  and  during  pregnancy  and  their 
persistence  thereafter.  Improper  body  posture,  often  exaggerated 
)3y  poorly  fitted  or  improperly  adjusted  corsets  and  defective  shoes, 
also  has  its  influence  in  the  same  direction. 

The  structures  that  are  most  subject  to  injury,  and  in  Avhich  such 
injury  is  most  likely  to  persist,  are  those  of  the  cervix  with  its  sur- 


2        THE  GYNECOLOGY  OF  OBSTETRICS 

rounding  tissues,  the  pelvic  diaphragm,  and  the  outlet.  From  the 
nature  of  its  structure  and  location,  the  uterus  itself  is  only  oc- 
casionally the  site  of  injury.  The  vaginal  canal,  on  account  of  its 
relatively  large  caliber,  permits  of  fairly  easy  distention.  With  its 
mucous  membrane  arranged  in  columns  and  rugae  so  as  to  be 
capable  of  covering  a  much  larger  area,  the  relation  between  the 


The  normal  cervix  at  a  point  above  the  junction  of  the  ventral  vaginal  wall.   At  this 
point  the  cavity  is  considerably  widened,  with  the  walls  nearly  in  apposition.  The  strati- 
fied squamous  epithelium  covers  the  portion  that  is  free  in  the  vagina. 

mucous  membrane  and  the  deeper  structures  is  maintained  in 
spite  of  the  difference  in  the  nature  of  the  component  elements. 
Consequently,  injuries  to  the  vagina  itself  are  less  frequent;  and, 
if  they  do  occur,  they  tend  to  repair  themselves,  on  account  of  the 
contracting  power  of  the  muscle  and  elastic  fibers  composing  the 
wall  and  the  mechanical  arrangement  of  the  mucous  membrane. 

In  using  the  term  cervix  throughout  this  monograph,  I  shall 
always  refer  to  what  should  technically  be  known  as  the  vaginal 


AXATO:yIV  OF  TIIK  CKRVIX  AX  I)  PKRINEUM  3 

poftioii  of  the  ('(M\ix.  The  line  cci-vix  is  that  portion  of  the  uterus 
heyoiidthe  plane  at  wliicli  the  peritoneum  i-eflects  upon  the  bladder. 
It  is  at  tiiis  plane  that  tlie  constrietioii  of  tlie  uterine  cavity  known 
as  the  internal  os  oeeurs.  The  cervix  extends  through  the  vaginal 
\ault,  as  it  were,  with  a  slight  ventral  curve  to  the  external  os.  That 
part  (»r  the  uterus  lying  in  the  vagina  is  known  as  the  vaginal  por- 
tion of  tile  cervix.  Tlie  os  is  so  sitnated  that  it  points  directly  to- 
ward the  hollow  of  the  sacrum  and  meets  the  tactile  end  of  the  su- 
pine examining  finger.  Any  variation  from  this  location  indicates 
an  abnormal  position  of  the  uterus,  an  al)normal  relation  of  the 
true  cervix  to  the  body,  a  disj)lacement  of  the  uterus  from  pressure 
by  some  ontw^ard  mass,  or  a  distortion  of  the  cervix  itself  by  scar- 
tissue  contraction.  In  a  retrodisplaced  uterus  the  os,  as  a  rule, 
points  in  the  direction  of  the  vaginal  canal.  By  some  this  is  given 
as  a  point  diagnostic  of  reti'oversion,  with  the  result  that  the  care- 
less examiner  is  apt  to  overlook  a  condition  of  marked  anteflexion, 
especially  Avhere  the  body  cannot  be  easily  palpated. 

The  vaginal  portion  of  the  cervix  varies  considerably  in  size  in 
different  individuals.  AVe  find  all  variations,  from  the  small  conical 
cervix  of  the  girl  with  an  anteflexed  uterus  to  the  large  liypertro- 
])hied  cervix  of  the  woman  with  a  chronic  endocervicitis,  or  vaginal 
prolapse.  The  anteflexed  uterus  is  a  persistence  of  what  in  premen- 
strual life  is  a  normal  flexion  of  the  cervix  and  body,  Init  which, 
when  inflammation  is  present,  causes  the  patient  to  suffer  from 
dysmenorrhea,  leucorrhea,  and  possible  sterility — an  entity  spoken 
of  as  anteflexion.  A  normal  intravaginal  cervix  is  about  three- 
fourths  of  an  inch  in  length  and  about  an  inch  in  breadth,  tapering 
somewhat  tow  ard  the  truncated  end,  w^here  the  external  os  is  situ- 
ated. The  thickness  is  a  little  less  than  the  breadth.  The  os  is  a 
circular  opening  about  one-eighth  of  an  inch  in  diameter ;  and  if  an 
imaginary  line  be  extended  across  the  os  it  divides  the  cervix  into 
a  ventral  and  a  dorsal  lip.  The  ventral  lip  is  somewhat  shorter,  but 
meets  the  examining  finger  first,  on  account  of  the  relation  of  the 
vaidt  of  the  vagina  to  the  horizontally  placed  uterus. 

The  supravaginal  portion  of  the  cervix  is  about  three-quarters  of 
an  inch  long  and  of  slightly  greater  dimensions  than  the  intravagi- 
nal, narrowing  somewdiat  at  the  junction  with  the  corpus,  or  body, 


THE  GYNECOLOGY  OF  OBSTETRICS 


^9^ 


All  i.'iilan 


ciiiciit   of  the  iKii'iiial  strat  ili('<l  s(]iiaiiiuiis  ('|iitlR'liuiii 
of  the  vaginal  cervix. 


of  the  uterus.  This 
portion  of  the  cer- 
vix is  attached  to 
the  fundus,  or  base, 
of  the  bladder  in 
front,  yet  with  a 
fairly  well  -  marked 
cleavage  line.  Be- 
hind it  is  covered 
l)y  the  peritoneum 
of  the  pouch  of 
Douglas  and  later- 
ally b}^  the  base 
of  the  broad  liga- 
ments. 

The  cervical  ca- 
nal is  somewhat  fusiform  in  shape,  the  narrowest  portions  being  at 
the  internal  and  external  ora.  In  cross-section  it  represents  a  flat- 
tened oval,  the  walls  not  being  in  as  close  contact  as  in  the  body.  The 
mucous  membrane 
differs  from  that 
in  the  uterine  cav- 
it^^,  in  being  some- 
what denser,  on  ac- 
count of  a  greatei- 
amount  of  fibrous 
tissue  in  its  struc- 
ture, and  in  possess- 
ing a  higher  layer 
of  columnar  epithe- 
lium, and,  most  im- 
portant of  all  to  the 
medical  man,  mu- 
cous glands  that  are 
larger,  more  branch- 
ing than  in  the  uter- 


ine   body    mucosa. 


A  segment  of  the  transverse  section  of  the  cervix  more  highly 
magnified,  showing  the  character  of  the  lining  membrane  of 
the  cavity  with  the  penetration  into  the  deeper  tissues  of  the 
cervical  glands.  The  deep  location  of  the  branches  of  the 
glands  shows  the  impossibility  of  removing  any  but  the  very 
superficial  tissue  by  a  curette. 


ANATOMY  OF  TIIK  CKIJVIX   AX  I)  I'ERIXEUM 


and  of  i-acciiiosc  instead  of 
tul)iilai'  t_\|)<'.  TIk'So  glands 
arc  loniAcr,  and  often  ex- 
tend their  l)liii<l  ends  in 
Ix'tweeii  the  mnsch'  lihei's. 
Tlieir  secretion,  iTiilike  the 
thin,  Avatery  flnid  from  the 
body  inlands,  is  a  eh'ar, 
exceedin.gly  tenacions  Jini- 
cns,  which  in  inlhmnna- 
tions  of  the  cervix  forms 
tlie  plug  so  difficult  to  re- 
move. The  obstruction  of 
the  orifices  of  the  cervical 
glands  allows  the  collec- 
tion of  the  contents,  result- 
ing in  what  Xaboth  de- 
scribed as ''ovules."  These 


A  still  higher  magiiificatiuii  of  tlie  lining  membrane 
of  the  cervix,  showing  more  in  detail   the  single 
I'eteiltion    CVSts    freCIUentlv      la,yer  of  cells  with  the  basement  membrane  that 

forms  the  covering  of  the  epithelial  layer. 


1-eacli  the  size  of  a  small 

jiea.   and    sliow  lieneath   the 


A  cross-section  of  the  nui'iiml  crrxii-.-il  imih-hik  mriiilir:i m-  tlinl" 
shows  the  character  of  the  gland  stiuetiue  and  the  propor- 
tional relation  to  the  intei'stitial  tissue. 


vaginal  mucous  membrane  as  hard 
rounded  nodules, 
wliitish  yellow  in 
appearance  where 
the  pressure  has 
thinned  the  mu- 
cous membrane. 

The  lining  of  the 
cervical  canal  has 
upon  its  surface 
a  ventral  and  a 
dorsal  longitudinal 
ridge  from  Avhicli 
depressions  run 
obliquely,  as  the 
branches  from  a 
tree.    This   forma- 


6        THE  GYNECOLOGY  OF  OBSTETRICS 

tion  is  known  as  the  "  arbor  vitae. "  At  certain  times  of  the  men- 
strual cycle  the  epithelium  is  descrihecl  as  ciliated.  The  transition 
from  the  cylindrical  epithelium  of  tke  canal  to  the  stratified  squa- 
mous epithelium  covering  the  vaginal  surface  is  abrupt  at  the  os, 
so  that  in  tears  of  the  cervix  the  columnar  epithelium  becomes  ex- 
posed and  subject  to  friction  and  erosion.  The  main  structure  of 


Tliis  spccimon  is  intendcMl  to  '-i  i  \  c  a^  a  <•  iin|),n  imhi  tui  rli(  latiT 
illustrations  tlial  show  the  eaily  iiulicatioiis  of  nialigiiaiu*y. 
Where  the  cells  are  cut  at  a  right  angle,  the  uniform  character  of 
the  cells  with  the  type  of  basement  membrane  is  typical  of  the 
normal  cervical  lining.  The  vascular  character  of  the  endometrium 
is  well  shown  by  the  blood-vessels  close  to  the  epithelial  covering. 

the  cervix  consists  of  the  involuntary  muscle  tissue  arranged  in 
layers  surrounding  the  canal,  with  some  oblique  bundles  of  fibers 
but  no  longitudinal  layer.  The  muscle  is  intermingled  with  a  con- 
siderable amount  of  dense  fibrous  and  elastic  tissue,  which  ac- 
counts for  the  greater  resistance  and  hardness  of  the  cervix  over 
the  bod}^ 

The  nerve  supply  of  the  uterus,  being  designed  for  the  control  of 


ANATO:V[Y  OF  TIIK  CHR\'IX  AXI)  PKRIXEl'M 


tlie  involuntary  muscle  fihcis,  is  ahuixlaiit.  The  nerves  are  of  lar<i;e 
size,  to  corresi)()ii(l  to  the  lii,<;lil\-  (levelojjed  niyometriuni.  According 
to  Piersol,  tliey  are  derived  fioin  the  sympathetic  nervous  system, 
as  a  continuation  from  the  hypogastric  ph'xns  thi-ongli  tiie  i)elvic 
plexus,  conihinini;-  with  branches  from  the  second,  third,  and  fourth 
sacral  spinal  nerves.'  The  ganglia,  though  rnumerous,  are  small. 
The  largest  is  the  "  cervical  ganglion."  This  receives  fibers  direct- 
ly fi-oni  the  spinal  nerves  and 
is  situated  behind  tlie  upper 
portion  of  the  vagina.  Thence, 
through  the  broad  ligament  as- 
sociated with  the  lilood-vessels, 
this  cervical  ganglion  supplies 
the  uterus,  the  major  portion 
supplying  the  muscle  cells.  The 
character  of  the  nerve  suppl}^ 
and  the  relatively  smaller  num- 
ber of  fibers  to  the  cervix,  to- 
gether with  the  large  amount 
of  fibrous  and  elastic  tissue, 
have  been  given  as  the  reason 
for  the  comparative  lack  of 
sensation  in  the  vaginal  cervix, 
which  permits  us  to  grasp  the 
lips  without  causing  pain.  Ac- 
cording to  Poirer  and  Charpy, 
the  nerves  of  the  uterine  neck 
are  more  numerous  and  thicker         ,  ..,     ,       ^       .  ^, 

or  change  in  the  character  or  the  secretion, 
than  those  of  the  body,  and  the  producing  a  cystic  condition  designated  as 
statement    that    there'  is    feeble  '^'*^'  endometritis  or  endocervicitis. 

sensibility  is  inexact.  It  is  well  to  bear  in  mind  that  by  applying  the 
vulsellum  slowly  and  steadily  the  gradual  pressure  anesthetizes 
the  mucous  membrane.  We  thus  avoid  practically  all  sensation,  ex- 
cept when  the  cervix  is  excessively  inflamed.  The  single-pointed 
tenaculum  causes  just  as  much  sensation  as  the  small  double-tooth 
vulsellum,  and  is  very  nmch  more  likely  to  pull  out,  thus  giving  a 
torn,  bleeding  cervix  and  often  necessitating  a  reapplication. 


Since  it  has  been  shown  that  all  the  micro- 
scopical findings  supposed  to  characterize  the 
various  forms  of  endometritis  are  found  in 
the  normal  uterus  during  the  menstrual  cy- 
cle, the  only  point  at  the  present  time  that 
is  considered  diagnostic  of  chronic  endome- 
tritis and  endocervicitis  is  the  round-cell  in- 
filtration. The  inflammatory  process  is  some- 
times sufficient  to  cause  obstruction  to  the 
glands,  either  through  pressure  on  the  outlet 


8        THE  GYNECOLOGY  OF  OBSTETRICS 

The  dorsal  lip  of  the  cervix  has  less  sensation  than  the  ventral, 
and,  as  a  rule,  is  just  as  convenient  to  grasp.  In  replacing  a  retro- 
displaced  uterus  and  applying  a  pessary,  the  dorsal  lip  is  the  more 
convenient,  for  the  vulsellum  acts  as  a  guide,  thus  directing  the 
upper  bar  behind  the  cervix.  In  a  case  of  badl}^  lacerated  cervix,  if 


A  higher  magnification  of  a  cystic  ciiiloinctriuiii  that 
shows  the  round-cell  infiltration.  The  glands  are  all  more 
or  less  enlarged,  though  the  number  appears  relatively 
decreased  on  account  of  the  increase  of  interstitial  tissue. 
The  main  cavity  has  lost  its  epithelial  lining,  as  will 
occur  from  excessive  internal  pressure. 

the  ventral  lip  is  grasped,  the  pessary  may  slip  into  the  cleft  and 
be  rather  difficult  to  dislodge  to  its  dorsal  position,  especially  if  it 
is  necessary  to  use  one  with  a  sharp  curve. 

The  blood  supply  of  the  cervix  comes  mainly  from  the  uterine 
artery,  which,  at  the  level  of  the  internal  os,  gives  lateral  branches 
running  in  front  and  behind,  which  anastomose  to  form  the  circular 
artery  of  the  cervix  as  well  as  another  branch — the  vaginal  artery, 
which  passes  downward  to  supply  the  vagina  and  cervix.  It  is  from 


ANATOMY  OF  THE  CKKVIX  AXI)  PKRIXEUM  9 

these  vessels  that  tlic  only  l)le('(liii,i;-  of  iiiii)()rtaiK'e  is  likely  to  occur 
ill  injuries  at  coiihiieiiieiit  or  operations  on  the  cervix.  As  a  rule, 
the  first  sutures  placed  laterally  at  the  depth  of  the  ^\■oull(l  readily 
control  such  hlccdiui;'. 

In  all  operative  work  on  and  ai-ound  the  cervix  the  adjoining- 
structures  have  to  be  borne  in  mind.  The  most  important  of  these 
are  the  bladder  and  ureters.  In  simple  operations  on  the  cervix 
these,  as  a  nde,  are  not  likely  to  he  injured.  In  some  cases  of  cysto- 
cele,  associated  as  they  often  are  in  old  women  with  an  atrophic 
cervix,  the  vaginal  and  bladder  walls  are  excessively  thin  and  the 
bladder  is  very  close  to  the  os,  on  account  of  the  small  ventral  lip. 
Again,  in  uterine  prolapse  the  bladder  is  carried  down  with  the  cer- 
vix, and  may  be  entered  in  doing  plastic  work  on  the  cervix.  A 
sound  introduced  into  the  bladder  and  turned  toward  the  cervix 
will  locate  the  reflection  of  the  bladder  and  help  to  avoid  such  in- 
jury. It  is  only  in  the  removal  of  the  uterus,  in  high  amputations 
of  the  cervix,  in  resection  of  the  vaginal  vault,  or  in  the  separation 
of  the  bladder  from  the  uterus,  as  in  the  interposition  operation, 
that  the  ureters  are  likely  to  be  encountered.  In  severe  injuries  of 
childbirth,  the  ureters  are  occasional!}^  involved,  giving  rise  to 
ureteral  fistulae. 

The  ureters  having  their  termination  at  the  upper  and  outer 
angles  of  the  bladder  trigone,  are  thus  situated  apart  about  a  width 
and  a  half  of  the  cervix,  where  they  are  in  close  proximity  to  the 
vaginal  vault.  From  there  they  diverge  rajDidly  outward  and  back- 
ward in  the  base  of  the  broad  ligament,  so  that  at  the  lateral  aspect 
of  the  cervix  they  are  about  three-quarters  of  an  inch,  or  two  centi- 
meters, away,  and  are  here  crossed  by  the  uterine  arteries.  Still 
diverging,  they  pass  retroperitoneally,  so  that  as  they  cross  a  line 
drawn  between  the  two  anterior  superior  spines  they  have  reached 
their  widest  separation  at  the  pelvic  walls,  and  are  here  one  and 
three-quarter  inches  approximately  from  the  lateral  as^ject  of  the 
cervix.  Running  upward  and  slightly  inward  on  the  natural  slope 
of  the  pelvis,  the  ureter  meets  the  internal  iliac  vessel  before  its 
division,  accompanying  it,  but  situated  ventrally,  until,  at  the  pelvic 
brim,  the  common  iliac  artery  is  crossed  just  about  at  the  bifurca- 
tion. In  cases  where  the  abdomen  is  opened,  the  ureters  may  be 


10       THE  GYNECOLOGY  OF  OBSTETRICS 

made  more  visible  b}'  stroking  the  peritonemn  covering  them.  This 
irritation  causes  a  peristaltic  contraction  of  the  muscle  fibers  and 
makes  the  structure  more  easily  visible  and  palpable. 

The  danger  of  injury  to  the  rectum  is  slight  if  ordinary  care  is 
used,  for  between  it  and  the  cervix  is  imposed  the  double  layer  of 
peritoneum. 

The  lymphatics  are  of  interest  in  connection  with  cancer  forma- 
tion. According  to  Piersol,  those  from  the  cervix  form  two  to  four 
large  trunks  that  follow  the  uterine  artery  and  veins  outward,  and, 
l3dng  in  the  lower  and  outer  part  of  the  broad  ligament,  pass  to 
lymph  nodes  occupying  the  angle  between  the  external  and  internal 
iliac  arteries. 

The  vaginal  canal  runs  cephalad  and  dorsad  at  an  angle  of  about 
sixty  degrees  to  the  perpendicular  with  the  patient  in  the  dorsal 
position.  It  is  well  to  bear  in  mind  that  the  direction  of  the  canal 
does  not  change  its  relation  to  the  patient  when  any  other  posture 
is  assumed,  but  always  is  directed  toward  the  hollow  of  the  sa- 
crum. The  remembrance  of  this  relation  will  facilitate  the  intro- 
duction of  the  speculum  and  prevent  impinging  on  a  possibly  sen- 
sitive ventral  vaginal  wall. 

The  vagina  is  a  collapsed  tube  with  the  upper  and  lower  walls 
in  apposition.  On  account  of  the  relation  of  the  uterus,  the  ventral 
or  upper  wall  is  about  an  inch  shorter  than  the  dorsal.  The  lower 
portion  of  the  canal  dips  into  the  vulva  as  does  the  cervix  into  the 
vagina,  and  here  is  the  narrowest  portion  of  its  caliber,  the  upper 
portion  of  the  canal  being  several  times  larger.  The  columns  and 
rugae  into  which  the  mucous  membrane  forms,  and  the  circular 
muscle  fibers  with  the  large  quantity  of  elastic  tissue  composing 
the  walls,  permit  of  extreme  distention  without  injury.  The  vagina 
is  in  close  contact  with  the  urethra  and  bladder  in  front  and  the 
rectum  behind,  but  separated  therefrom  b}^  a  well-defined  fascia 
layer,  to  which  both  organs  have  a  rather  loose  connection,  with 
well-defined  cleavage  lines.  In  the  normal  individual  this  fascia  has 
as  great  a  strength  as  the  fasciae  of  the  abdomen ;  and  the  blending 
into  other  fascia  layers  at  the  lateral  attachments  to  the  pelvic  wall 
is  well  marked  and  of  great  support  value.  As  we  shall  see  later, 
these  fasciae  in  injury  resulting  in  cystocele  and  rectocele  become 


Platk  I 

A  MEDIAN  SECTiOX  THROUGH  THE  FEMALE  PELVIS 

AT  THE  SYMPHYSIS  PUBIS  — THE  PELVIC 

ORGANS  ARE  IN  NORMAL  RELATION 


I  WaII 
Il6<i  bftjek  ) 

W^ 

1  CmiM[  ^i 

1 

^ 

^^^             Coce^ 

^ 

-^ 

ZZl^MUS 

The  median  section  of  the  female  pelvis.  The  peritonemn  removed 
from  over  the  brim  of  the  pelvis  and  ureter  shows  the  internal  iliac 
artery  in  its  relation  to  the  ureter.  The  beginning  portion  of  the  exter- 
nal iliac  vessels  is  shown  with  peritoneum  removed.  The  course  of  the 
external  iliac  vessels  along  the  brim  of  the  pelvis  is  outlined  beneath 
the  peritoneum  where  the  round  ligament  runs  toward  the  inguinal 

canal. 


Plate   II 

A  :\1EI)IAX   SECTION  TllKOl'OlI  THE  FEMALE  PELVIS 

AT  THE  SY:\rPHYSIS  PUBIS  —  THE  UTERUS 

DISPLACED  IX  ORDER  TO  SHOW  THE 

RELATION  OF  THE  URETER  TO  THE 

ICTERUS  AND  BLADDER 


A  longitudinal  section  through  the  pelvis.  The  surfaces  of  the  blaclcler, 
uterus,  and  vaginal  vralls  have  been  colored  red.  In  the  upper  field  the 
peritoneum  reflection  from  the  bladder  has  pulled  away  from  the 
pubic  symphysis,  exaggerating  the  space  of  Retzius.  The  uterus  is 
retrodisplaced  in  order  to  put  the  left  broad  ligament  on  tension.  The 
peritoneum  over  the  ventral  surface  of  the  broad  ligament  is  removed 
exposing  the  uterine  artery  and  the  ureter  to  its  entrance  into  the 
bladder.  The  round  ligament,  colored  red,  is  shown  in  its  course  to 
the  inguinal  canal.  This  illustration  takes  up  the  course  of  the  ureter 
beneath  the  broad  ligament  at  the  point  of  disappearance  in  the 
preceding  plate. 


AXATOMV  OF  TIIK  (1^H\'IX  AND  PKRINEr.M         11 

('\c('ssi\('l\-  thill,  l)iit  oil  account  of  tlic  stroii,!;-  lateral  attacliiiiciits 
must  not  he  iicglcctcMl  in  the  r('|»aii-  work. 

The  mucous  menihraiie  of  the  \a,!Aiiia  is  of  the  stratirie(l  s(|ua- 
iiious  ty|)e  witii  few  secretiiift' glands  and  a  suhmucous  hiyer  loosely 
attachin.iA'  it  to  the  muscle  layers.  The  muscle  wall  consists  mostly 
of  circular  lihei-s,  with  only  a  few  longitudinal,  intermixed  with  a 
large  amount  of  elastic  tissue.  The  ])lo()d  supply  comes  wholly  fi'om 
the  internal  iliae  arteries  through  various  channels.  The  u])i)er 
part  of  the  vagina  is  supi)lie(l  ])y  the  cervical  hranches  of  the  utei'- 
ine  arter\- — these,  running  down,  communicate  with  hi-anches  from 
the  middle  hemorrhoidal  and  vesicovaginal  that  supply  the  middle 
and  h)wer  portions  of  the  vagina  respectively. 

According  to  Piersol,  the  nerves  to  the  vagina  are  from  the 
same  source  as  those  to  the  cervix,  except  that,  at  the  low^er  portion 
and  toward  the  orifice,  some  fibers  coming  from  the  pudic  nerve  en- 
dow the  mucous  membrane  of  the  lower  third  with  greater  sensibil- 
ity and  send  motor  filaments  to  the  striated  muscles  surrounding 
the  entrance.  Consequently,  the  upper  part  of  the  vaginal  canal 
possesses  sensibility  only  of  the  same  moderate  degree  that  is 
found  in  the  cervical  structures. 

Anatomists  difi^er  not  only  regarding  the  nerves, but  also  regard- 
ing the  lymphatics.  According  to  Piersol,  the  lymphatics  within  the 
mucous  membrane  form  a  close  network  that  connnunicates  with 
the  lymph-vessels  of  the  muscular  coat.  The  collecting  branches 
from  the  upper  and  middle  thirds  of  the  vagina,  in  company  with 
those  from  the  cervix,  pass  chiefly  to  the  lymph  nodes  along  the  in- 
ti^-nal  iliac  artery.  Some  from  the  posterior  vaginal  wall  go  around 
the  bowel  and  terminate  in  the  rectal  and  lumbar  nodes.  The  lym- 
l)hatics  from  the  vicinity  of  the  vaginal  orifice  pass  chiefly  to  the 
u})per  median  groups  of  inguinal  nodes ;  a  few,  however,  go  the 
same  course  as  the  ones  from  the  upper  vagina. 

The  vagina,  with  the  urethra  and  rectum,  pierces  what  is  known 
as  the  pelvic  diaphragm  and  exits  through  the  pelvic  floor  into  the 
vulva.  The  pelvic  diaphragm  consists  of  a  muscle  called  the  levator 
ani,  with  a  fascia  layer  above  and  below.  In  three  normal  subjects, 
the  numljer  so  far  dissected,  I  have  found  that  these  layers  are 
pretty  thoroughly  blended  with  the  muscle  fibers.  The  deeper  fas- 


12       THE  GYNECOLOGY  OF  OBSTETRICS 

cia,  wliicli  is  known  as  the  rectovesical,  Avas  in  these  subjects  more 
loosely  attached  and  more  of  a  sliding  la^^er  than  the  lower  or  so- 
called  anal  fascia. 

The  rectovesical  fascia  is  a  direct  continuation  of  the  pelvic  fas- 
cia, and  takes  its  origin  from  Avhere  the  iDelvic  fascia  spans  the  ob- 
turator muscle  between  the  two  bony  attachments — one  on  the  inner 
surface  of  the  pubic  bone,  and  the  other  on  the  inner  surface  of 
the  ischial  tuberosity.  This  bridge  is  reinforced  wdth  more  fibers, 
and  is  known  as  the  "  white  line."  From  this  and  the  bony  attach- 
ments arises  the  levator-ani  muscle.  The  pelvic  fascia,  while  end- 
ing in  name  at  the  "white  line,"  in  reality  continues  on  below  the 
rectovesical  reflection,  and  at  a  slightly  lower  level  again  splits 
into  two  layers — one  closely  blending  with  the  under  surface  of 
the  levator-ani  muscle  to  form  its  lower  covering,  and  known  as 
the  anal  fascia,  the  other  closely  covering  the  obturator-internus 
muscle,  and  known  as  the  obturator  fascia. 

On  account  of  the  divergence  of  the  pelvic  diaphragm  from  the 
bony  structures,  the  anal  and  obturator  fasciae  rapidly  increase 
their  distance  apart.  The  resulting  space  between  them  and  down 
to  the  pelvic  floor,  where  the  divergence  is  widest  and  where  the 
blending  of  these  layers  with  the  triangular  ligaments  takes  lolace, 
is  loosely  filled  with  fatty  tissue.  This  pyramidal  space  is  the  ischio- 
rectal fossa. 

Dr.  Irving  S.  Hajmes,  of  New  York,  in  a  paper  on  ''The  An- 
atomical Basis  of  Perineal  Repair,"  describes  the  fasciae  as  fol- 
lows : 

"  If  the  anal  fascia  has  been  removed  and  the  lower  surface  of 
the  levator  ani  exposed,  by  gently  using  the  fingers  or  the  handle 
of  a  scalpel,  it  will  be  found  that  the  levator  ani  and  the  parietal 
X)elvic  fascia  are  easily  separated  as  one  layer  from  a  more  exter- 
nal la^^er  of  fascia,  which  is  the  '  true  '  obturator  fascia.  This  layer 
covers  the  obturator  muscle  and  is  attached  to  bone  and  ligament 
all  about  its  margin,  viz.,  along  the  iliopectineal  line,  to  the  upper 
margin  of  the  obturator  groove  and  to  the  inner  surface  of  the 
pubis,  below  to  the  spine  of  the  ischium,  to  the  great  sacrosciatic 
ligament,  tuberosity  of  the  ischium  and  the  ischiopubic  ramus. 

"  The  inner  layer  is  the  parietal  pelvic  fascia,  which  for  its  up- 
per attachment  follows  the  same  lines  as  the  true  obturator  fascia 


ANATOMY  OF  TIIK  CKRVIX  AXI)  PERINEUM         13 

(loos,  but  after  tlie  limits  of  tlic  ()])tui-ator  muscle  are  ])assed,  ex- 
tends over  the  ])yi-iformis  muscle  as  the  i)yi-ifoi-mis  fascia,  and  is 
in  this  rei^ion  attaclie(l  to  the  postei'ior  portion  of  the  iliopectineal 
line,  the  fi-ont  of  the  sacrum,  the  ,<2,reat  saci-osciatic  lii;ament  and 
the  s])ine  of  the  ischium.  This  fascial  j)lane  di-ops  downward  and  is 
called  the  pai'ietal  pelvic  fascia  until  a  ])oint  is  i-eaclie(l  where  it  is 
thickened  by  the  addition  of  some  fibers  runnin.i'-  anteroposteriorly 
from  the  inner  surface  of  the  pu])is  to  the  s])ine  of  the  ischium,  the 
so-called  'white  line';  below  this  line  the  fascia  is  called  the  vis- 
ceral ])elvic  fascia,  and  it  is  disi)osed  as  previously  given.  There  is 
thus  foi-med  a  continuous  plane  or  layer  of  fascia,  tiie  upper  part 
of  wliich  is  usually  described  as  the  parietal  pelvic  fascia  and  the 
lower  j)ortion  as  the  visceral  ])elvic  fascia,  but  the  two  p)ortious 
are  really  continuous  with  each  other  without  any  uiark  of  separa- 
tion except  for  the  thickeuing  at  the  'white  line,'  but  the}^  are 
se})arated  from  the  true  obturator  fascia.  The  origiu  theu  is  usual- 
ly giveu  for  the  visceral  layer  of  the  same  as  well. 

"  The  levator  aui  shows  two  distinct  portions,  the  iliococcygeus 
and  the  pubocoecygeus  (puborectalis). 

"  The  iliococcygeus  is  the  i)ortion  arising  from  the  'white  line.' 
It  is  inserted  into  the  side  of  the  rectum,  the  anococcygeal  raphe 
or  ligament  and  the  coccj^x. 

''  The  pubocoecygeus  arises  from  the  inner  surface  of  the  i)ulns, 
passes  backward  alongside  of  the  vagina  to  be  inserted  into  the 
tendinous  center  of  the  perineum,  and  sweeping  around  the  rec- 
tum, it  terminates  in  the  anococcygeal  ligament  and  coccyx.  This 
})ortion  of  the  nmscle  deserves  further  notice.  Its  fibers  form  a 
strong  band  (about  three-eighths  of  an  inch  wide)  which  hugs  the 
vaginal  orifice  very  closely  (forming  the  lateral  compressor  of  the 
vagina),  and  is  inserted  in  a  'Y-shaped'  manner.  One  leg  of  the 
'  Y  '  terminates  in  the  central  tendon  of  the  perineum,  the  other 
leg  of  the  '  Y '  encircles  the  rectum  and  ends  in  the  anococcygeal 
ligament." 

In  my  three  dissections  of  the  normal  female  pelvis  the  levator 
ani  has  been  divided  into  three  distinct  segments.  One,  the  small- 
est and  most  ventral,  and  having  its  origin  mainly  from  the  pubic 
bone,  runs  downward  and  inward  across  the  upper  portion  of  the 
l)ubic  arch  to  be  attached  into  the  side  of  the  urethra  and  vagina. 
As  is  shown  by  these  dissections  and  the  operative  findings,  the 
middle  portion,  frequently  overlapping  the  dorsal  edge  of  the  ven- 
tral segment,  is  also  attached  to  the  sides  of  the  vagina,  even  as 


14       THE  GYNECOLOGY  OF  OBSTETRICS 

high  as  an  inch  in  some  individuals.  It  sends  a  well-defined  bimdle 
of  fibers  between  the  vagina  and  rectum. 

The  third  and  larger  section  of  the  muscle  is  continuous  with  the 
dorsal  edge  of  the  middle  segment  at  its  point  of  origin,  but  fre- 
quently is  overlapped  by  that  segment  toward  the  median  line.  All 
of  its  fibers  go  behind  the  rectum  and  form  a  sling  for  that  struc- 
ture. It  is  on  the  upper  surface  of  this  section  that  we  find  the  loos- 
est attachment  of  the  rectovesical  fascia. 

The  attachment  of  the  levator  ani  to  the  sides  of  the  vagina  and 
the  band  of  fibers  running  between  the  vagina  and  rectum  are  de- 
nied by  some  gynecological  writers ;  but,  so  far,  in  every  case  of  un- 
injured iDerineum  the  findings  have  been  constant  and  the  evidence 
presented  in  the  illustrations  is  incontestable.  Poirer  and  Charpy 
are  also  authority  for  the  same  statement.  It  is  this  lateral  attach- 
ment that  prevents  the  prolapse  of  the  lower  segment  of  the  vagina 
in  procidentia. 

The  gynecologist  deals  mainly  with  distorted  anatomy ;  the  anat- 
omist does  not  always  have  the  surgical  point  of  view;  and  so  it 
is  not  always  possible  to  correlate  the  descriptions  found.  This  is 
emphasized  too  by  the  fact  that  in  individual  cases  the  normal  an- 
atomical findings  vary.  But  it  is  on  the  recognition  of  these  find- 
ings in  the  pelvic  diaphragm  and  their  proper  application,  that  the 
success  of  plastic  work  upon  that  and  the  outlet  will  depend. 

The  attachment  of  the  levator  ani  is  mainly  in  a  central  raphe, 
the  ventral  portion  also  attaching  to  the  sides  of  the  urethra  and 
vagina  and  the  dorsal  segment  to  the  sides  of  the  coccyx.  This  me- 
dian raphe  blends  into  what  is  known  as  the  pelvic  floor,  making  it 
almost  impossible  to  separate  the  structures  without  cutting.  This 
blending  of  the  diaphragm  and  floor  is  another  anatomical  fact  not 
generally  recognized  in  considering  perineal  injuries  and  repairs. 
There  is  a  small  triangular  gap  left  in  this  diaphragm,  with  its 
base  at  the  sides  of  the  sacrum  and  coccyx  and  its  apex  at  the  spine 
of  the  ischium.  This  gap  is  filled  in  by  a  muscle  variously  described 
as  the  coccygeus  or  ischiococcygeus,  and  which  has  little  impor- 
tance from  the  gynecological  aspect. 

By  most  anatomists  the  levator  ani  is  described  as  one  muscle 
without  definite  segments,  and  in  his  work  on  anatomy  Piersol 


Plate  III 

SEd.MEXT  OF  THE  LEVATOR-AXI  MUSCLE 

HI  XXIXG  BETWEEX  THE  VAGINA 

AND  THE  RECTUM 


6u)t  of  v«5+ii>, 

LFvAtof^  Ami 
{^^•ddlc  3£gme-nt> 

Under  Sl;(^f^ee 


ofk  ja/itEo  VNc!f« 


In  this  section  the  lower  portion  of  the  vaginal  wall  has  been  par- 
tially cut  away  and  pulled  to  the  side  in  order  to  get  it  out  of  the 
field.  The  central  tendon  is  cut  through,  and  the  segment  of  the  leva- 
tor ani  between  vagina  and  rectum  is  intact  over  the  strip  of  cloth. 


Aj'J 


Platk   IV 

TIIK  I'ELVIC  DIAPHRAOM  AND  THE  ATTACHMENT 

OF  THE  LEVATOK-AXI  :\rrSCLE  TO  THE 

SH3E  OF  THE  VAGINA 


■to    Pybrc  A(?(?K*' 

Le^/A^oR  An  I 

witti  Ana 


evc/?eo 
nxeaf 


Coggyy 


All  the  structures  on  the  subject's  right  have  been  removed  down 
to  the  ' '  pelvic  diaphragm. ' '  The  relation  of  the  muscle  and  the 
anal  fascia  to  the  median  line  of  the  pelvis  with  the  blending  into 
the  superficial  structures  is  shown.  On  the  other  side  the  dissection 
has  been  carried  between  the  levator  ani  and  the  vagina,  in  order 
to  show  the  attachment  between  the  two.  In  this  case,  on  the  left 
side  the  separation  of  the  sphincter  vagina  into  superficial  and 
deep  has  not  been  possible. 


^1*  4  d.',. 


Antis 


ANATO^IY  OF  THE  CERVIX  ANM)  PERTXEUM         15 

tliiis   (Icscrilx'S   it.    But    under   tlic    licadiii.i;'   of  "  A^ai-iatious  "   lie 
makes  the  rollowiii.i;'  statenieiit  : 

'"J'lie  levator  ani  is  always  a  well-developed  musele,  altliougli 
the  extent  of  its  attachment  to  the  sides  of  the  coccyx  vai'ies  in- 
versely to  the  attachments  of  the  coccygeus  to  that  bone.  There  is 
usually  to  be  found  a  dividing  line  extending  aci-oss  the  muscle  on 
a  level  with  the  junction  of  the  superior  rannis  of  the  pubic  with 
the  ilium  and  separating  those  fibers  which  are  inserted  onto  the 
coccyx  and  the  posterior  ])ortion  of  the  fibrous  i-aplie  from  those 
which  pass  to  the  anterior  part  of  the  raphe  and  the  rectum.  Each 
of  the  portions  so  separated  is  supplied  by  a  separate  nerve,  and 
this,  combined  with  the  results  of  comparative  anatomy,  seems  to 
show  that  the  posterior  portion  of  the  levator  is  really  a  muscle 
quite  distinct  from  the  anterior  portion.  It  has  been  termed  the  m. 
iliococcygeus.  Furthermore,  it  seems  probable  that  the  anterior 
portion  is  composed  of  two  morphologically  distinct  muscles,  one 
of  which  arises  from  the  pubis  and  anterior  part  of  the  Svhite 
line  '  and  is  inserted  into  the  median  fibrous  raphe,  w^hence  it  is 
termed  the  m.  pubococcygeus,  while  the  other,  situated  beneath — 
i.  e.,  superficial  to  the  pubococcygeus — consists  of  those  fibers 
which  arise  from  the  pubis  and  are  inserted  into  the  rectum,  and  is 
termed  the  m.  puborectalis." 

In  my  dissections  the  muscle  has  been  distinctly  divisible  into  the 
three  segments  as  described,  and  in  each  case,  as  is  well  shown  in 
the  illustrations,  the  edge  of  the  individual  segment  is  distinct  and 
overlapping,  with  a  definite  space  between.  In  each  subject  the  at- 
tachment of  the  ventral  and  middle  segments  to  the  vagina  has 
been  most  marked,  and  yet  the  anatomy  text-book  fails  to  mention 
the  fact,  even  under  "Variations."  It  is  extremely  important  to 
the  gynecologist  in  accounting  for  the  various  conditions  resulting 
from  the  relaxed  vaginal  outlet  to  bear  this  anatomical  relation  in 
mind,  for  upon  a  proper  understanding  of  this  relation  will  depend 
the  correct  results  in  plastic  work. 

Those  structures  which  fill  in  the  area  between  the  pubic  arch  in 
front  and  the  edge  of  the  giuteus-maximus  muscles  behind  are 
spoken  of  as  the  pelvic  floor.  The  structures  composing  this  floor 
are  variously  described  by  different  authorities,  and  in  reality 
they  vary  rather  markedly  in  different  subjects.  In  some  cases  the 
muscles  are  well  marked  with  large  well-defined  bellies,  but  rather 


16       THE  GYNECOLOGY  OF  OBSTETRICS 

at  the  expense  of  the  fasciae.  In  others  the  fascia  layers  are  the 
most  prominent,  while  some  of  the  mnscles  are  poorly  defined ;  but 
in  all  cases  the  nmscle  tissue  forms  a  large  element  of  support.  The 
central  tendon  in  some  women  contains  an  excessive  amount  of 
elastic  tissue,  the  presence  of  which  may  account  for  lack  of  injury 
to  the  pelvic  floor  in  childbirth.  This  will  naturally  not  prevent  the 
levator-ani  injury,  and  may  deceive  the  obstetrician  as  to  the  ex- 
tent of  the  vital  injury. 

This  variation  of  composing  elements  probably  accounts  for  the 
difference  of  opinion  of  gynecological  writers  as  to  the  value  of 
one  element  over  another  for  building  a  perineal  support.  Physi- 
ology tells  us  that  fasciae  will  alwa^^s  stretch  under  continued  ten- 
sion if  no  rest  is  given,  and  it  is  only  by  rest  that  they  can  recuper- 
ate ;  whereas  muscle  tissue  develops  with  exercise,  but  only  within 
certain  limits.  Consequently,  all  over  the  body  where  strength  is 
required  but  where  variation  in  area  is  necessary  we  find  both 
muscle  and  fascia  closely  associated  and  often  blended. 

Where  excessive  stretching  has  occurred,  a  tearing  of  the  fasciae 
has  resulted,  possibly  without  muscle  rupture,  and,  consequently, 
by  excessive  elongation,  the  muscle  cannot  function.  By  shortening 
up  the  fasciae,  and  thus  giving  the  muscle  a  new  point  of  attach- 
ment, it  is  again  set  to  work  and  develops  strength,  and  this  is  the 
mechanism  of  a  successfully  repaired  pelvic  outlet.  Consequently, 
both  the  surgeon  who  emphasizes  the  importance  of  the  fascia  and 
the  surgeon  who  emphasizes  that  of  the  muscle  are  correct,  but  only 
in  part.  When  it  comes  to  muscle  rupture  as  well  as  fascia  injury, 
the  retracted  ends  of  the  vaginal  portion  of  the  levator  ani  become 
imbedded  in  scar  tissue.  That,  however,  is  a  factor  Avhich  will  be 
considered  more  fully  under  perineal  repairs. 

The  pelvic  floor,  ventral  to  the  tuberosities  of  the  ischia,  practi- 
cally consists  of  three  layers  of  fascia,  between  which  are  situated 
muscle  layers ;  and  these  layers,  pierced  by  the  urethra  and  vagina, 
may  be  considered  as  bridging  the  area  within  the  pubic  arch.  Dor- 
sal to  this  line  is  found  one  layer  of  fascia,  for  here  the  same 
amount  of  structural  support  is  not  necessary  and  greater  possi- 
bility for  expansion  must  be  allowed.  The  superficial  layer  of  the 
outer  fascia  is  closely  blended  to  the  skin,  and  cannot  be  considered 


ANA'rOMV  OK  TIIK  CKKN'IX   AND  rKIMNKlM  17 

of  iiiucli  \-alii('  rroiii  llic  siir,L;(M»ii 's  stniidpoiiit  other  than  in  sci-viiii;- 
to  picvcnt  the  movement  of  tlie  skin  on  the  deeper  structures  as  well 
as  suj)))lyiiii;'  some  sui)port.  It  is  a  contiimation  of  the  superficial 
fascia  of  the  tlii,i;ii  and  abdomen.  Ontlieremovaloftlie  skin  witlitliis 
fascia,  we  come  to  the. first  layer  of  fascia,  described  as  one  of  tlie 
three  su])port  layers.  This  fascia  is  coimnonly  known  as  ('o]l(^s's 
fascia.  It  is  a  (inn,  well-defined  layer  bound  down  to  the  pubic 
arch.  This  layer  is  continuous  niesially  in  some  subjects  with  the 
fascia  siirroundin.ij,-  the  vaji,ina  and  urethra.  In  other  subjects  the 
blendini;-  takes  phice  in  the  median  line  witli  the  muscle  tissue,  and 
a  direct  connection  cannot  be  traced  with  the  internal  fasciae.  The 
removal  of  this  layer  exposes  the  first  muscle  structures  of  the 
pelvic  floor  and  their  central  tendon  attachments.  This  fascia  is 
closely  attached  to  the  dorsal  edge  of  the  triangular  ligament. 

The  most  important  of  these  muscles  are  the  two  sphincter  vagi- 
nae, or  l)ulbocavernosi,  which  have  their  origin  at  the  ventral  edge 
of  the  central  tendon,  and  thence  run  forward,  one  on  either  side 
of  the  vaginal  orifice  and  vestibule,  dividing  into  three  septa, 
which  attach  themselves,  one  to  the  body  of  the  clitoris,  one  to  the 
sides  of  the  bulbs  of  the  vestibule,  and  the  ventral  portion  running 
over  the  clitoris  and  blending  into  the  fasciae  and  suspensory  liga- 
ment. In  most  subjects  it  is  impossible  to  separate  this  muscle  from 
the  corresponding  deeper  muscle  called  the  compressor  vaginae 
except  at  the  attachment  to  the  central  tendon.  Since  surgically 
such  a  separation  is  of  no  value,  from  this  on  the  two  will  be  con- 
sidered as  the  sphincter  vaginae.  Corresponding  to  this  muscle  in 
the  dorsal  portion  of  the  perineal  region  is  the  sphincter  ani,  aris- 
ing at  the  dorsal  edge  of  the  central  tendon,  running  around  the 
anus,  and  attached  to  the  coccyx.  The  body  of  the  muscle  is  well 
defined  and  inclosed  in  a  reflection  of  fascia  spoken  of  as  the 
sheath.  Both  muscles  depend  oi;  the  central  tendon  for  one  point 
of  support,  and  so,  in  cases  of  injury  to  the  central  tendon,  the 
muscles  retract,  and  thus  increase  the  distance  between  the  anus 
and  vestibule. 

From  the  side  of  the  central  tendon  outward,  to  be  attached  on 
the  pubic  arch  a  little  forward  of  the  tuberosity  of  the  ischium,  run 
the  transversus  iDerinei.  The  superficial  are  not  always  as  well- 


18       THE  GYNECOLOGY  OF  OBSTETRICS 

defined  muscle  bodies  as  the  deep,  which  have  relatively  the  same 
attachments,  but  are  situated  between  the  layers  of  the  triangular 
ligament.  In  some  subjects  the  combined  muscles  are  as  much  as  a 
quarter  of  an  inch  in  diameter ;  and  with  the  patient  in  the  dorsal 
position,  the}^  run  a  little  upward  and  outward  from  the  horizontal. 
Between  the  central  tendon  attachments  of  the  sphincter  vaginae 
and  transversus  perinei  superficial  the  erector  clitoridis  has  its 
origin  and  then  continues  outward  at  the  ventral  edge  of  the  latter 
muscle,  filling  in  j)artially  the  triangular  space  between  these 
muscles  and  the  pubic  rami.  It  passes  over  the  crura  and  is  inserted 
into  the  pubic  rami.  The  greater  portion  of  the  muscle  belly  is  to- 
ward the  rami,  so  that  a  considerable  gap  is  often  left  between  it 
and  the  sphincter  vaginae. 

Beneath  these  muscles  the  superficial  layer  of  the  triangular  lig- 
ament is  stretched,  blending,  however,  in  the  muscle  gaps  with 
Colles's  fascia  and  the  deep  layer  of  the  triangular  ligament,  so  that 
in  some  subjects  it  is  difficult  to  separate  the  individual  layers, 
making  it  appear  to  be  a  heavy  one-layer  fascia  that  splits  to  in- 
close the  muscle  structures.  In  the  median  line  the  fascia  blends 
with  the  lateral  aspect  of  the  sphincter  vaginae,  and  this  again  with 
the  rectovesical  reflected  layers  surrounding  the  vaginal  canal.  At 
the  bony  boundary  the  fasciae  are  firmly  attached,  and  here  are 
readily  separated  into  the  various  layers,  with  a  considerable  frac- 
tion of  an  inch  gap  between.  At  a  line  drawn  from  tuberosity  to 
tuberosity,  the  superficial  layer  of  the  triangular  ligament  is  re- 
flected back  around  the  deep  transversus  perinei  and  becomes  the 
deep  layer  of  the  triangular  ligament  with  the  same  lines,  of  attach- 
ment. 

Between  these  two  layers  occur  the  deep  transversus  perinei,  the 
deep  sphincter  vaginae,  or  so-called  constrictor  vaginae,  already 
described,  and  a  third  muscle,  corresponding  to  the  erector  clitori- 
dis, called  variously  the  constrictor  urethra,  compressor  urethra, 
or  Guthrie's  muscle,  but  not  always  well  defined,  especially  if  the 
superficial  set  of  muscles  are  well  developed.  At  the  sides  of  the 
vagina  and  between  the  deep  layer  of  the  triangular  ligament  and 
the  under  layer  of  the  anal  fascia,  blending  with  the  levator  ani, 
are  situated  the  bulbs  of  the  vestibule,  one  on  either  side.  These 


Plate  \' 
THE  :\rT^l^CLES  OF  TTTE  PELVIC  FLOOR 


^/  -  <r/4?K 


Ou  the  left  side  the  layers  of  the  triangular  ligament  are  dissected 
off:  the  muscles.  The  superficial  muscles  (which  in  this  subject  were 
not  so  well  defined)  were  unseparated.  The  right  side  of  plate  shows 
some  ill-defined  superficial  muscle  fibers  (colored  red).  At  the  side 
of  the  clitoris  the  superficial  layer  of  the  triangular  ligament  laid 
over  exposes  the  main  ventral  attachment  of  the  so-called  sphincter 
vaginae.  Pieces  of  white  cloth  are  laid  under  the  muscles  to  em- 
phasize their  free  edges. 


Plati:  Y1 

TllK  (JLAXD  OF  BARTHOLIN 
THE  BULB  OF  THE  VESTIBULE 


f^ectAl  TossA 


The  dissection  at  the  side  of  the  vagina  has 
been  carried  between  the  layers  of  the  triangu- 
lar ligament,  in  order  to  expose  the  gland  of 
Bartholin  (colored  brown)  and  the  vestibulo- 
vaginal  bulbs  (colored  blue).  The  fascia  layer 
dissected  off  the  gland  has  been  pulled  aside 
over  the  cloth. 


ANATOMY  OF  THE  CERVIX  AXI)  I'KRIXEUM         19 

structures,  composed  of  cavernous  venous  spaces,  are  about  an 
inch  and  a  (juarter  long,  lialf  an  inch  wide,  and  vary  in  tliick- 
ness  from  one-eighth  to  one-cpiarter  inch.  To  tlie  inner  side  of 
these  l)hMi(l  the  anal  fascia  of  tlie  levator  ani  and  the  sphincter 
vaginae.  Surgically,  these  structures  are  not  of  much  iiiii)oi-tance, 
for  from  their  situation  they  are  seldom  injured. 

Two  other  structures,  one  on  either  side  of  the  vagina,  are  of  im- 
portance. These  are  the  glands  of  Bartholin.  They  are  compound 
i-acemose  glands  situated  between  the  layers  of  the  triangular  liga- 
ments and  opeidng  by  ducts  just  external  to  the  hymen.  When  nor- 
mal they  secrete  a  thin  mucus  as  a  lubricant  against  friction,  and 
this  is  markedly  increased  under  nerve  stimulation.  At  the  conclu- 
sion of  micturition  the  contraction  of  the  vaginal-sphincter  muscles 
probably  produces  a  more  profuse  discharge,  as  a  protection 
against  the  urine.  Not  only  are  the  glands  of  Bartholin  of  interest 
from  the  fact  that  they  are  subject  to  inflammation  in  gonorrheal 
infection  as  well  as  occasionally  to  cyst  and  abscess  formation,  but 
the  orifices,  opening  as  they  do  midway  in  the  vaginal  slit,  offer  a 
landmark  in  perineal  repair. 

As  a  rule,  the  ventral  relation  of  the  orifice  of  the  gland  of  Bartho- 
lin is  not  distorted  in  injuries  of  the  outlet.  Occasionally  a  ventral 
tear  distorted  by  scar-tissue  formation  displaces  the  orifice  back- 
ward, and  care  must  be  taken  to  avoid  including  the  duct  in  the  de- 
nudation for  perineorrhaphy. 

The  urethra,  running  along  the  ventral  vaginal  wall,  is  separated 
therefrom  by  a  well-marked  fascia  layer.  Its  orifice,  situated  in  the 
vestibule,  is  twice  the  distance  from  the  vaginal  orifice  as  from  the 
under  surface  of  the  clitoris  at  the  f renuni.  The  lateral  boundary  of 
the  vestibule,  being  marked  by  a  crease  in  the  mucous  membrane 
whei'e  the  closely  anchored  vestibule  membrane  is  reflected  off  on 
to  the  labia  minora,  gives  us,  with  the  midline  location  of  the  ure- 
thral meatus,  definite  landmarks,  even  if  swelling  is  present  and 
structures  are  distorted.  In  passing  the  catheter  it  is  well  to  re- 
member that  the  urethra  is  firmly  attached  to  the  pubic  arch  and 
that  the  direction  of  the  canal  is  curved  under  the  symphysis. 

In  extensive  relaxation  of  the  ventral  vaginal  wall  with  the  blad- 
der-sag, the  urethra  usually  remains  firmly  attached  at  its  lower 


20 


THE  GYNECOLOGY  OF  OBSTETRICS 


end  to  the  pubic  arch,  but  the  bladder  portion  is  displaced  down- 
ward, so  that  the  tip  of  the  glass  catheter, inserted  first  in  the  direc- 
tion of  the  curve  of  the  symphysis,  must  be  jDointed  dor  sally  to  reach 
the  bladder  cavity  instead  of  in  the  continued  ventral  trend  in  the 
normal  individual.  In  these  cases  where  catheterization  is  difficult 
a  glass  of  larger  dimensions  may  usually  be  passed  with  ease,  since 
the  mucous  membrane  folds  are  thus  straightened  out. 

The  rectum  is  separated 
from  the  fornix  of  the  vagi- 
na b}'  the  folds  of  the  pouch 
of  Douglas.  From  these  folds 
to  the  level  of  the  jDclvic  dia- 
phragm the  layer  of  fascia 
attached  to  both  structures 
is  the  only  intervening  ele- 
ment. Where  the  muscle  of 
the  pelvic  diaphragm  comes 
betw^een  the  vagina  and  rec- 
tum, the  rectum  runs  dorsal- 
ly  from  there  to  the  anal  ori- 
fice for  the  last  inch  of  its 
course.  The  introduction  of 
the  speculum  is  consequently 
ventrad  and  cephalad  for 
the  first  inch,  and  then  dor- 


sad, following  the  hollow  of 

the  sacrum. 

The  fasciae  of  the  pelvic 

floor  in  the  median  line  are 

blended  closely  with  the  anal 
fasciae  of  the  pelvic  diaphragm,  so  that  in  some  cases  it  is  not 
possible  to  find  the  cleavage  line  or  separate  the  attachments  of  the 
levator  ani  from  the  sides  of  the  vaginal  sphincter  or  the  attach- 
ment of  the  transversus  perinei,  where  both  run  into  the  central 
tendon.  The  bundle  of  fibers  running  between  the  vagina  and  rec- 
tum, however,  are  usually  free  from  the  fascia  covering  and  can  be 
picked  up  between  the  fascia  layers  enfolding  them.  As  the  two 


This  illustrates  a  normal  virgin  vulva  in  a  girl 
of  sixteen.  The  labia  minora  are  not  fully  de- 
veloped. The  tubercle  of  the  vagina  protrudes 
more  than  usual.  The  urethral  orifice  is  placed 
comparatively  high  on  account  of  the  greater 
prominence  of  the  vaginal  tubercle. 


Plate  VII 
THE  ISCHIORECTAL  FOSSAE 


Clitat^tcl  IS 


«c«y>; 


In  this  stage  of  the  dissection  the  ischiorectal  fossae  have  been 
cleared.  The  superficial  and  deep  muscles  on  the  left  of  the  plate 
have  been  removed  close  to  their  attachments,  exposing  the  crus,  the 
bulb  of  the  vestibule,  and  the  anal  fascia  layer.  The  vaginal  wall 
dissected  from  its  surroundings  dorsally  and  laterally  has  been 
drawn  together  and  pushed  inward. 


ANATOMY  OF  TIIK  CP]RV1X  AND  PP^RTNEUM         21 

planes   (tlie  (liapliraii,!!!  and  the  floor)   run  ontwai'd  to  the  i)ubic 
ai-('li,  they  become  farther  apart,  so  tliat  at  the  pelvic  wall  they 
ai-e  separated  by  almost  the  width  of  the  pubic  bone.  Between 
these  layers  we  iind  the  bulbs  of  the  vestibule  and  the  crura  to- 
gether with  the  blood  and  nerve  supply.  The  rectal  area  already 
outlined  is  dorsad  to  the  reflections  of  the  layers  of  the  triangular 
ligaments   over  the  transversus   perinei,   and  this   area  can  be 
sui)erficially  defined  by  a  line  between  the  tuberosities  of  the 
ischia.  In  this  region  the  only  structures  of  importance,  aside  from 
the  oi-ilice  of  the  rectum,  with  the  external  sphincter  ani,  in  the 
lucMlian  line,  are  the  ischiorectal  fossae.  These  two  spaces  are  tri- 
angular in  base  as  well  as  in  elevation.  Each  base  area  is  outlined 
in  its  connnon  median  line  by  the  sphincter  ani,  ventrally  by  the 
''  ischioperineal  ligament  "  (as  the  edge  of  the  triangular  ligament 
is  sometimes  called),  and  on  the  third  side  by  the  gluteus-maximus 
muscle  and  sacrosciatic  ligament.  The  elevation  is  bounded  toward 
the  me  sad  line  by  the  lower  surface  of  the  rectal  sling  of  the  leva- 
tor ani  and  the  anal  fascia,  laterally  by  the  tuberosity  of  the  ischi- 
um, and  above  that  by  the  obturator  fascia  covering  the  obturator- 
internus  muscle.  These  areas  are  filled  with  loose  connective  tissue 
in  which  is  a  large  amount  of  fatty  tissue,  but  with  no  structures  of 
importance  except  some  blood-vessels.  Behind  the  rectimi  the  fos- 
sae are  separated  only  by  the  fascia  attachments  of  the  rectum  to 
the  sacrum.  The  obturator  fascia  forming  the  lateral  wall  is  a  re- 
flection from  the  anal  fascia,  and  consequently  abscess  formations 
in  the  ischiorectal  fossa  are  prevented  from  burrowing  above  the 
pelvic  diaphragm.  It  is  these  areas  loosely  filled  that  allow  of  the 
excessive  distention  of  the  vagina  in  childbirth  and  of  the  rectum 
in  normal  function. 


MECHANICS  OF  THE  RELAXED  OUTLET 

FROM  the  nature  of  its  structure,  the  pelvic  diaphragm,  com- 
posed as  it  is  of  the  levator  ani  and  the  rectovesical  and 
anal  fasciae,  is  essentially  of  an  elastic  character.  In  the  nor- 
mal individual  it  is  practically  a  perfect  shelf,  for  the  ca- 
nals that  pass  through  it  run  at  an  acute  angle  to  its  plane,  much  as 
does  the  inguinal  canal  in  the  abdominal  wall.  It  is  designed,  aided 
by  the  reinforcing  support  of  the  pelvic  floor,  to  bear  its  share  of 
the  weight  of  the  abdominal  contents  and  to  overcome  through  its 
elasticity  the  various  strains. 

The  pelvic  floor  aids  the  diaphragm  as  a  weight-carrier,  but  has 
a  more  specialized  function  of  maintaining  the  relation  of  the  vari- 
ous outlets  to  one  another  and  to  the  pelvic  walls.  The  muscle  ele- 
ments in  its  structure  control  the  functions  of  each  orifice. 

The  blending  of  the  diaphragm  with  the  floor  gives  the  former 
more  x)oints  of  anchorage,  since  the  tension  and  firmness  of  the  tri- 
angular ligaments  prevent  any  lateral  motion. 

The  pelvic  diaphragm,  being  similar  in  structure,  has  the  same 
function  as  the  abdominal  wall.  Through  its  contraction,  it  has  the 
same  power  of  supporting  the  pelvic  contents  in  cases  of  strain 
coming  from  above  and  caused  by  forcible  contraction  of  the 
thoracic  diaphragm,  either  under  exertion  or  the  involuntary  action 
of  sneezing  or  coughing.  Besides  the  diaphragmatic  action  of  the 
levator  ani,  this  muscle  has,  as  its  name  signifies,  a  direct  function 
to  perform  in  connection  with  the  rectum.  The  same  levator  func- 
tion applies  to  the  vagina  in  a  lesser  degree  through  the  power  of 
the  fibers  placed  between  the  vagina  and  rectum  and  the  attach- 
ment to  the  sides  of  the  vagina  and  the  urethra. 

In  extensive  injuries  of  the  perineum,  meaning  thereby  injury 
not  only  to  the  floor,  but  also  to  the  diaphragm,  and  commonly 
spoken  of  as  a  relaxed  vaginal  outlet,  a  serious  modification  of  the 
normal  relations  of  the  structures  takes  place.  This  abnormal  rela- 
tion may  not  result  immediately  ujdou  the  production  of  the  injury, 


MECHANICS  OF  THE  RELAXED  OUTLET     23 

for  tlio  scar  tissue  t'oriiuMl  in  tli(^  attempt  to  repair  will,  through 
its  contraction,  delay  tlie  relaxation.  The  resulting  but  temporary 
support  obtained  is  only  of  short  duration,  since  scar  tissue,  or 
even  fascia,  will  not  stand  any  continued  sti-ain  without  stretching, 
and  because  the  important  muscles  have  contracted  and  pulled  back 
with  them  certain  of  the  fascia  layers  to  which  they  are  intimately 
attached.  The  length  of  useful  support  from  nature's  handicapped 
method  of  repair  depends  altogether  on  the  amount  of  strain  ap- 
plied and  the  degree  of  injury.  The  effects  are  always  progres- 
sive, and  never  in  an  injured  perineum  does  the  destructive  proc- 
ess stand  still. 

The  ventral  rectal  wall  has  lost  its  support  through  the  injury  of 
the  levator  ani  and  its  fasciae.  The  destruction  of  the  central  peri- 
neal tendon  allows  the  retraction  of  the  external  sphincter  of  the 
anus,  with  a  consequent  increase  of  the  distance  from  the  vestibule 
to  the  rectum.  Thus  the  expulsive  force  of  the  rectum  acts  in  a  ven- 
tral instead  of  a  dorsal  direction,  and  this  continued  expulsive 
pressure  combined  with  the  weight  of  the  bowel  contents  stretches 
the  rectovaginal  septum,  forming  a  rectocele.  The  walls  of  the  rec- 
tocele  thicken  through  unaccustomed  exposure  to  friction,  and  thus 
more  weight  is  added.  The  more  this  vaginal  septum  protudes,  the 
less  nmscular  tone  the  rectum  possesses,  since  the  muscle  layers 
become  atrophic  through  excessive  stretching,  and  thus  permit  of 
further  fascia  stretching. 

The  same  process  goes  on  with  the  bladder  in  relation  to  the  ven- 
tral vaginal  wall,  though  more  sIoavIj^  at  first,  because  of  the  close 
attachment  of  the  bladder  to  the  uterus  and  the  firm  attachment  of 
the  urethra  to  the  pubic  arch.  The  ventral  vaginal  wall  depends 
most  largely  for  its  vital  support  on  the  integrity  of  the  dorsal 
structures,  and  even  though  only  slightly  injured,  will  quickly 
show  the  effect  of  the  perineal  defect. 

The  cystocele  and  rectocele  have  been  spoken  of  as  hernias  of  the 
bladder  and  rectum,  but  in  the  majority  of  cases  they  are  in  reality 
hernias  of  the  ventral  and  dorsal  vaginal  septa.  In  some  cases  of 
forceps  delivery  the  fasciae  split,  and  then  a  true  hernia  of  the 
rectum  and  bladder  ma^^  occur,  and  in  these  cases  the  increase  in 
the  size  of  the  protrusion  is  rapid.  On  examination  one  can  palpate 


24       THE  GYNECOLOGY  OF  OBSTETRICS 

a  definite  hernia  ring  of  fascia.  In  ordinarj^  eystocele  and  reetocele, 
however,  the  fasciae  are  only  overstretched  and  atrophic,  and  if 
rest  be  given  by  pntting  the  patient  to  bed  or  by  placing  a  pessary 
to  support  the  cervix,  the  recuperation  and  gain  in  tone  is  surpris- 
ing, though,  of  course,  evanescent. 

The  eystocele  formation  is  at  first  slow,  on  account  of  the  fairly 
firm  attachments  of  the  ventral  vaginal  wall  and  the  urethra  to 
the  sides  and  under  surface  of  the  pubic  arch,  and  the  support  of 
the  sides  of  the  vagina  and  urethra  by  the  levator  ani.  Soon,  how- 
ever, due  to  the  hydrostatic  power  of  its  contents,  the  development 
of  the  protrusion  is  more  rapid.  On  account  of  the  continuedpressure 
of  urine  stretching  out  the  vaginal  septa,  any  marked  improve- 
ment is  imjDOssible,  and  in  time  the  difficulty  of  operative  repair  is 
greatly  exaggerated.  A  slight  improvement  results  from  the  con- 
tinued recumbent  posture,  with  its  avoidance  of  friction,  and  thus 
the  lessening  of  congestion.  This  improvement  is  slight,  on  account 
of  the  weight  of  urine  that  is  always  present.  If  a  pessar^^  is  ap- 
plicable, it  can  accomplish  more,  on  account  of  the  splintlike  sup- 
I)ort  from  its  rigidit}^ 

If  the  uterus  were  a  fixed  organ,  probably  the  injurious  effects 
might  end  with  the  production  of  the  eystocele  and  reetocele,  for 
the  uterus  under  normal  conditions  lies  in  a  horizontal  position, 
and  any  pressure  on  its  upper  surface  would  tend  to  force  it  on  the 
bladder  in  a  more  anteverted  position.  There,  on  account  of  the  re- 
lation of  the  pelvic  and  abdominal  cavities  to  each  other  and  the 
rather  firm  fixation  of  the  cervix  at  its  normal  level,  it  is  thrown 
parallel  with  the  plane  of  the  pelvic  diaphragm  and  acts  as  a 
valve,  closing  the  rent  in  that  structure  as  well  as  pressing  to- 
gether the  vaginal  walls.  The  uterus,  however,  is  not  a  fixed  organ, 
for  provision  has  to  be  made  for  the  variation  in  size  of  the  blad- 
der and  rectum  in  daily  life  and  the  enlargement  of  the  uterus 
itself  in  pregnancy.  To  be  a  fixed  organ,  it  must  have  suspensory 
ligaments.  It  has  ligaments,  but  excepting  the  sacrouterine  they 
are  not  suspensory  ligaments.  Even  the  sacrouterine  are  not  true 
suspensor}^  ligaments,  though  they  approach  nearest  to  that  func- 
tion. If  all  the  pelvic  and  al^dominal  structures  are  in  normal  con- 
dition, the  uterus  stays  in  place  practically  without  the  aid  of  the 


MECHANICS  OF  THE  RELAXED  OUTLET     25 

ligaments,  and  oiilx  wlicii  tlic  distcMitioii  of  the  ])ladder  and  rectum 
occurs  do  we  find  the  ligaments  placed  under  any  tension. 

The  intact  pei'iiieum  keeps  the  abdominal  and  pelvic  cavities 
closed.  Thus,  under  balanced  opposing  forces  and  in  the  resulting 
closed  chamber,  the  uterus  practically  floats  with  even  pressure  on 
all  sides  except  what  may  bo  exerted  by  the  variation  in  cavity  con- 
tents and  respiration. 

Any  injury  to  the  levator  ani  and  its  inclosing  fasciae  that  de- 
stroys the  function  of  the  diaphragm  permits  the  entrance  of  air 
within  the  vagina,  and  thus  this  uterine  balance  is  immediately  dis- 
turbed and  the  structures  supporting  the  cervix  are  compelled  to 
bear  the  strain  intended  for  the  diaphragm.  These  structures, while 
firm  enough  to  be  most  important  in  maintaining  the  position  of 
the  uterus  under  normal  conditions,  are  only  of  fascia  composition 
and  are  bound  to  stretch.  Combined  with  the  injury  to  the  relaxed 
vaginal  outlet,  more  or  less  relaxation  occurs  at  this  plane,  so  that 
the  cervix  sinks  somewhat,  and  as  it  does  the  body  becomes  more 
perpendicular.  This  position,  known  as  the  first  degree  of  retro- 
version, compels  the  fundus  to  bear  the  brunt  of  the  now  most  ac- 
tive force,  designated  as  intra-abdominal  pressure,  and,  with  the 
uterus  sinking  lower  in  the  pelvis,  the  uterine  ligaments  begin  to 
act  as  suspensory.  The  circulation  is  interfered  with,  the  body  be- 
comes heavy  and  congested  and  flexes  on  the  cervix,  giving  a  retro- 
flexion. Now,  the  uterus  has  no  tendency  to  return  to  the  normal 
position  by  itself,  for  all  the  pressure  from  above  is  on  the  caudal 
surface  and  the  pressure  of  the  bowel  contents  makes  a  valve  of  the 
fundus.  For  a  time  the  uterus  remains  stationary  at  the  same  level, 
except  as  it  varies  within  minor  limits  with  the  changes  in  pressure 
in  the  abdomen  from  respiration  and  straining  and  the  weight  of 
the  bowel  contents,  for  the  ligaments  are  suspensory,  and  only  as 
they  stretch  does  prolapse  occur. 

When  we  consider  the  strength  of  the  cervical  supports  and  the 
comparative  inf  requency  of  severe  degrees  of  prolapse  in  premeno- 
pause  life,  it  is  hardly  justifiable  to  consider  prolapse  wholly  as  a 
sequence  of  retrodisplacement.  From  the  nature  of  the  mechanics, 
a  retrodisplacement  is  bound  to  be  a  forerunner  of  procidentiae, 
but  ]irolapse  as  a  sequel  is  not  of  sufficient  frequency  to  retrover- 


26       THE  GYNECOLOGY  OF  OBSTETRICS 

sion  to  wholly  account  for  its  prodnction.  In  young  women,  when 
prolapse  occurs,  it  comes  on  after  precipitous,  severe,  prolonged, 
or  instrumental  deliveries.  Its  onset  is  usually  rapid,  so  it  seems 
more  rational  to  explain  the  condition  by  acknowledging  extensive 
injuries  to  the  ligaments  and  attachments  of  the  cervix  and  upper 
vagina  than  wholly bythe  conditions  producing  retrodisplacements. 
In  women  beyond  the  menopause,  complete  prolapse  frequently 
occurs  suddenly,  and  this  is  due  to  the  rapid  giving  way  of  the 
same  structures  grown  atrophic  with  age  and  continued  strain. 
Prolapse  operations,  then,  which  will  take  into  consideration  the 
strengthening  of  the  tissues  at  the  cervical  level  as  well  as  the 
associated  relaxed  vaginal  outlet,  will  be  the  most  successful,  and 
failures  may  be  due  to  overlooking  these  factors. 

The  uterus,  having  sunken  to  the  point  where  the  upper  supports 
are  on  tension,  remains  there  just  as  long  as  these  supports  can 
resist  the  pull  from  below  and  the  pressure  from  above.  While  the 
pressure  downward  is  practically  a  non-increasing  force  within 
certain  limits,  the  pull  from  below  increases,  as  has  been  shown, 
by  the  increased  weight  of  thickened  mucous  membranes  and  the 
increase  of  the  residual  capacity  of  the  bladder  and  rectum.  This 
unaccustomed  pull  of  the  rectocele  and  cystocele  on  the  already  en- 
larged and  softened  cervix  results  in  a  gradual  stretching  out  and 
further  hypertrophy  of  that  organ.  The  greater  the  friction  exerted 
by  the  vaginal  walls  on  the  displaced  cervix,  the  greater  this 
hypertrophy,  so  that  in  some  severe  forms  of  cervical  elongation, in 
which  the  cervix  reaches  the  vulva  or  protrudes  from  the  vaginal 
canal,  the  elongated  and  hypertrophied  organ  may  be  four  and  five 
times  the  normal  width.  The  size  of  the  hypertrophied  cervix  in 
this  class  of  cases  may  be  even  longer  than  twice  the  length  of  the 
uterine  body.  The  cases  of  excessive  elongation  of  the  cervix  in 
which  the  uterine  body  remains  in  practically  normal  position  are 
still  another  reason  for  assuming  injuries  at  the  cervical  attach- 
ments as  the  controlling  cause  for  uterine  procidentia. 

The  cases  of  elongated  cervix  are  not  as  a  rule  associated  with 
as  severe  grades  of  rectocele,  for  the  cervix  by  its  splintlike  sup- 
port to  the  dorsal  vaginal  wall  takes  much  of  the  brunt  of  the 
pressure  of  the  fecal  contents,  and  as  the  fasciae  gain  strength  by 


MECHANICS  OF  THE  RELAXED  OUTLET  27 

sui)))()rt  tlic  iiiusc'lo  eleiiuMits  in  botli  tlie  walls  of*  tlie  va<2,iiia  and  the 
rectum  also  dcNcloi)  tlii()ii,ii,li  the  relative  shortening  between  their 
attachmeiit  i)oiiits.  In  cases  of  uterine  prola])se  we  also  find  the 
conii)aratively  smaller  rectocele  throngh  this  same  support  by  the 
uterine  body.  AVhat  is  true  of  the  rectocele  is  not  true  of  the  cysto- 
cele,  for,  witli  tlie  stretching-  of  the  cervix,  the  ])ladder,  through  its 
attachment  thereto,  is  also  stretched  out ;  and  correspondingly,  in 
cases  of  elongation  of  the  cervix  or  uterine  prolaj^se,  the  cystocele 
l)ecomes  a  most  ])rominent  protrusion. 

in  this  discussion  of  uterine  pathology  that  is  secondary  to  the 
relaxed  vaginal  outlet,  we  have  referred  to  the  force  that  acts  from 
al)ove  in  helping  to  produce  the  abnormalities.  Casual  considera- 
tion might  result  in  the  conclusion  that  gravity  was  the  greatest 
factor  involved,  and  that  in  time  it  could  produce  the  hernia  of  the 
pelvic  contents.  Tn  reality,  gravity  directly  plays  only  a  moderate 
]iart,  for  when  the  patient  is  erect  the  center  of  gravity  of  the  ab- 
domen, on  account  of  the  relation  of  the  abdominal  to  the  pelvic 
cavities,  falls  well  out  of  line  of  the  true  pelvis,  directly  upon  the 
bony  walls  and  the  lower  abdominal  muscle  wall.  The  direct  force 
of  gravity  becomes  indirect  in  the  pelvis  and  is  decreased  by  the 
friction  of  the  abdominal  contents  against  the  lower  abdominal 
wall,  especially  in  women  with  enteroptosis. 

The  force  from  above  that  exerts  the  greatest  power  is  in  reality 
a  combination  of  forces,  and  for  convenience  has  been  designated 
intra-abdominal  pressure.  The  question  of  what  intra-abdominal 
pressure  really  is,  in  fact  the  existence  of  such  a  factor  at  all,  has 
occupied  the  attention  of  many,  and  vain  attempts  have  been  made 
to  get  some  measure  of  its  poAver. 

Gravity  plays  a  most  important  part,  but  directly  counteracting 
that  force  is  a  factor  that  was  very  frequently  discussed  by  the 
older  writers,  and  designated  by  them  the  '"  retentive  power"  of 
the  abdomen.  This  "  retentive  power  "  of  the  abdomen  is  practical- 
ly the  condition  so  frequently  found  in  attempting  to  deliver  a 
pelvic  tumor  situated  low  in  the  pelvis  and  in  close  relation  to  its 
walls.  Not  until  we  can  admit  air  beneath  the  mass  does  the  groA\i:h 
come  up  easily.  This  condition,  of  course,  is  due  to  the  lack  of  dead 
spaces  within  the  abdomen,  and  is  nothing  more  than  the  effect  of 


28       THE  GYNECOLOGY  OF  OBSTETRICS 

air  pressure.  The  more  or  less  elastic  character  of  the  abdominal 
contents  and  the  containing  abdominal  muscle  makes  more  effective 
the  relative  vacuum  and  prevents  the  displacement  of  the  abdomi- 
nal contents. 

In  a  normal  closed  abdomen,  the  pelvic  cavity  also  included,  the 
pressure  on  any  one  j)oint  of  the  internal  wall  must  be  a  component 
of  at  least  three  factors.  The  first  of  these  factors  is  the  weight  and 
pressure  of  the  contents  of  the  hollow  structures,  these  contents 
being  either  solid,  liquid,  or  gaseous,  or  a  combination,  according  to 
the  nature  of  the  function  of  the  organ.  But  this  internal  force  is 
held  in  restraint  and  somewhat  counteracted  by  the  second  force, 
the  contractile  power  of  the  muscle  and  elastic  fibers  composing  the 
containing  walls,  aided  by  the  ligamentary  supports  of  the  various 
organs.  If  the  contents  of  an  organ  are  solid  or  liquid,  gravity 
alone  is  involved  in  the  production  of  excessive  distention.  But  in 
those  organs  where  fermentation  may  give  rise  to  gas  formation 
the  laws  of  gas  x)ressure  and  expansion  come  into  play.  Over  these 
two  forces  the  individual  has  no  voluntary  control.  The  third  force, 
on  the  other  hand,  is  almost  wholly  a  voluntary  one  and  exerted 
through  the  contractile  power  of  the  thoracic  and  pelvic  dia- 
phragms and  the  containing  lateral  muscle  walls.  The  abdominal 
walls  and  the  thoracic  diaphragm  act  largely  in  conjunction,  where- 
as the  pelvic  diaphragm  is  more  of  an  antagonist,  and  in  its  con- 
traction bears  the  strain  of  the  force  applied  by  the  thoracic  dia- 
phragm in  normal  respiration  or  involuntary  actions,  as  in  hic- 
coughing, vomiting,  etc. 

It  is  the  component  of  these  three  forces,  then,  that  determines 
the  character  and  degree  of  any  internal  abdominal  pressure,  and 
these  forces  can  in  many  wa^^s  be  modified;  for  instance,  excessive 
pressure  of  the  internal  contents  of  an  organ  will  cause  a  relative 
paralysis  of  that  organ's  muscle  fibers  and  prevent  emptying,  thus 
doing  away  with  the  controlling  second  force  and  allowing  great  in- 
crease of  the  first.  A  poison  acting  on  the  sympathetic  nervous 
system  ma^^  also  result  in  a  x)aralysis  of  the  muscle  fibers  pro- 
ducing the  same  results.  Peritoneal  inflammation  or  irritation  by 
direct  action  may  also  produce  paralysis.  In  a  normal  abdomen 
gravity  is  largely  a  potential  and  not  so  much  an  active  force.  It 


MECHANIC'S  OF  TWb]   HKI.AXKl)  OUTLET  29 

is  ('\'('i't(Ml  a(*ti\'('l\'  witliiii  llic  <'a\it\'  upon  tlic  soIkI  coiitoiits  of  tlie 
coiitniiiiiiii,'  or,i;'aiis,  and  upon  an  oi-,i;an  itself  that  has  h)st  its  suj)- 
poit,  sucli  as  we  find  witii  a  movable  kidney;  ])ut  upon  the  contents 
of  tile  abdomen  as  a  whole  it  is  practically  non-active,  l)ein<>-  dis- 
tril)iited  evenly  upon  tiie  intact  containing'  walls. 

Undci'  iioi-nial  conditions  tiiesc  forces  are  practically  balanced 
and  concern  us  little,  but  when  a  break  occurs  in  either  the  abdomi- 
nal wall  or  })elvic  dia])hra^ii,ni  this  balance  is  disturhed,  and  the  nor- 
mal forces,  meaning  therehy  gravity,  gas  distention,  and  pressure 
from  forcible  contraction  of  the  diaphragm  and  abdominal  walls, 
produce  serious  conditions  where  the  defect  is  not  remedied.  These 
normal  balanced  forces  can  hardly  be  designated  by  a  specific  name, 
but  when  the  balance  is  disturbed  we  are  justified  in  defining  the 
abnormal  relation  of  pressure  by  some  specific  term,  and  it  is  to 
this  abnormal  relation  that  the  name  ''intra-abdominal  "  pressure 
applies.  "Intra-abdominal"  pressure,  then,  is  the  comi)onent  of 
the  three  forces  found  in  the  normal  closed  abdomen,  with  an  in- 
crease in  the  force  of  gravit}'  the  lower  the  artificial  ox^ening  in 
the  retaining  walls,  but  again  restrained  somewhat  and  in  the  same 
increasing  ratio  by  the  so-called  "retentive  power"  of  the  ab- 
domen, or,  in  other  words,  air  pressure.  When  it  comes  to  the  pel- 
vic diaphragm,  the  gravity  of  the  abdominal  viscera  is  lessened,  as 
has  been  explained,  by  the  change  of  direction  of  the  force  and  by 
friction, but  the  weight  of  the  bladder  and  rectum  contents  is  added. 

In  the  case  of  each  individual  organ  having  suspensory  liga- 
ments the  sum  total  of  gravity  does  not  vary,  but,  on  account  of  the 
upper  i)oints  of  attachment,  the  place  upon  which  it  acts  with  a 
static  force  will  be  modified. 

Xow,  while  as  a  rule  an  abdominal  hernia  unrestrained  will  in- 
crease in  size  more  rapidly  than  the  pelvic  hernia,  this  is  not  wholly 
due,  as  might  be  supposed,  to  the  greater  force  of  gravity  exerted 
on  the  lower  abdomen  over  the  pelvis,  on  account  of  the  body  con- 
struction. In  the  pelvis  are  the  cervical  and  uterine  supports  bear- 
ing the  strain,  and  only  as  they  stretch  does  the  greater  degree  of 
procidentia  develop.  Consecpiently,  the  development  of  the  end  con- 
ditions of  the  relaxed  vaginal  outlet  is  of  insidious  onset,  but  al- 
ways progressive,  and  the  rai)idity  of  the  progression  depends  on 


30       THE  GYNECOLOGY  OF  OBSTETRICS 

so  many  factors  in  the  life  of  the  individual  woman  that  a  prog- 
nosis of  the  time  required  is  impossible.  What  may  occur  rapidly 
in  a  hard-working  individual  may  take  years  in  one  of  sedentary 
habits,  though  in  each  case  the  primary  pathology  may  have  seemed 
to  be  identical. 

But  neither  is  it  alone  the  individual's  activities  that  hasten  the 
process,  for  other  factors  concerning  the  resistance  of  fasciae  and 
scar  tissues  have  to  be  considered.  The  woman's  correctness  of  car- 
riage, the  proper  application  of  corsets,  the  care  during  subsequent 
pregnancies,  and  the  control  of  all  those  other  conditions  favoring 
pelvic  congestion  have  a  very  significant  bearing  on  the  final  out- 
come. "While  prophylaxis  in  all  those  things  which  favor  pelvic 
congestion  has  its  influence  on  the  final  outcome,  yet  the  process 
goes  on  progressively  until  the  repair  of  the  pelvic  diaphragm  and 
outlet  is  accomplished. 


ETIOLOGY  AND  PREVENTION  OF  LACERATIONS 

To  THE  ([uestioii  of  ctioloi^y  and  |)r('veiiti()u  of  eliil(n)irtli 
injuries  very  little  attention  is  ])ai(l  in  the  obstetrical  text- 
book outside  of  the  consideration  of  the  perineum  and  the 
means  reconnnended  to  prevent  injuries  there.  The  meth- 
ods advised  are  pretty  well  stereotyped,  and  practically  all  discus- 
sions consider  the  technique  of  the  most  normal  presentation,  the 
abnormal  cases  being  acknowledged  to  result  almost  invariably  in 
injury.  On  the  prevention  of  cervical  tears  little  is  said. 

Regarding  the  pi-evention  of  perineal  injuries  we  have  different 
methods  advocated.  Varnier  teaches  that  it  is  the  child's  forehead 
that  is  liable  to  cause  injury.  He  recommends  holding  back  the  fore- 
head so  as  to  prevent  extension  until  the  parietal  eminences  and 
neck  are  delivered  under  the  pubic  arch,  and  then  allowing  the 
slow  appearance  of  the  forehead,  nose,  mouth,  and  chin  successive- 
ly, and  that  preferably  in  the  interim  between  pains;  this  he  ac- 
complishes by  pushing  back  the  vulvar  parts,  and,  if  possible,  is 
aided  by  the  voluntary  expulsion  on  the  mother's  part.  He  thus 
acknowledges  that  it  is  the  rapid  expulsion  of  the  head  Avhich 
causes  the  greatest  danger.  If  delivery  is  accomplished  as  he  ad- 
vises, he  states  that  there  is  no  fear  of  perineal  tear.  Such  may  be 
true  if  the  relation  of  child  to  mother  is  not  abnormal  as  regards 
size. 

Hartmann  advocates  Varnier 's  method  and  rather  belittles  the 
frequently  recommended  supporting  of  the  dilating  perineum  by 
the  obstetrician's  hand,  "for  the  perineum  will  tear  under  the 
hand  supporting  it. " 

Peterson  says:  "In  spite  of  the  greatest  care,  lacerations  will 
occur  in  certain  cases,  but  if  the  obstetrician  is  skillful,  the  tear 
will  be  of  mininmm  size.  There  is  seldom  any  excuse  for  the  exten- 
sive rupture  upon  which  the  gynecologist  operates  later." 

The  fact  remains  that  the  more  skillful  the  obstetrician  the  less 
severe  the  injury,  but  that  there  is  no  excuse  for  the  extensive 


32       THE  GYNECOLOGY  OF  OBSTETRICS 

relaxations  found  later  is  not  true.  From  the  hands  of  the  best  ob- 
stetricians often  come  some  of  these  same  extensive  relaxations,  and 
the  reason  for  this  has  been  shown  in  the  chapter  on  the  results  of 
perineal  injury.  All  such  injuries  are  progressive,  and  many  re- 
sults seemingly  good  shortly  after  labor  lead  to  a  marked  degree 
of  relaxation  as  the  scars  stretch  and  muscles  atrophy.  The  in- 
juries which  are  the  result  of  the  giving  way  of  the  muscles  and 
fascia  beneath  the  uninjured  mucous  membrane  also  take  time  to 
develop. 

The  use  of  the  rubber  water-filled  bag  has  been  recommended  by 
Macomber  as  a  method  of  dilating  not  only  the  cervix,  but  also  the 
perineum,  and  thus  avoiding  excessive  injury.  He  advises  placing 
the  largest  bag  possible,  preferably  of  the  Voorhees  type,  within 
the  vagina  during  the  first  stage  of  labor.  He  claims  that  thus  the 
transmission  of  pressure  from  the  uterine  contraction  helps  the 
perineal  softening,  and  the  presence  of  the  bag  with  its  weight 
upon  the  outlet  stimulates  the  uterine  pains.  After  the  first  stage  is 
over,  the  descent  of  the  child  pushes  the  bag  ahead,  giving  a  more 
gradual  and  even  dilatation  than  would  be  accomplished  by  the  ver- 
tex, and  the  bag's  presence  still  acts  as  a  stimulator  of  uterine  con- 
tractions. 

In  the  opinion  of  some  obstetricians,  it  is  held  that  the  degree  of 
injury  can  be  more  readily  controlled  with  the  patient  in  the  lateral 
posture  rather  than  the  dorsal.  In  the  lateral  position  it  is  easy  to 
demonstrate  that  the  tear  begins  within  the  vagina,  and  that  in  most 
cases  the  diaphragm  gives  way  beneath  the  superficial  structures, 
an  occurrence  it  is  impossible  to  prevent. 

Another  method  advocated  for  the  prevention  of  injuries  is  the 
incision  of  the  vulva,  or  episiotomy.  According  to  Berkeley  and 
Bonney,  "In  exceptional  instances,  when  it  appears  certain  that 
the  head  cannot  be  born  naturally  without  a  severe  rupture  of  the 
perineum,  deliberate  incision  of  the  latter  should  be  performed. 
The  division  should  not  be  made  in  the  middle  line  but  to  one  side 
of  it.  Bilateral  incision  is  preferred  by  some  authorities." 

Hartmann,  already  quoted,  says :  "  The  little  incisions  in  the  vul- 
va are  useless  and  only  lead  to  tears.  If  the  central  tear  is  feared, 
make  an  oblique  incision  backward  and  outward ;.  a  median  section 


Plate  VIII 

THE  MUSCLES  OF  THE  VAGINAL  OUTLET  DISSECTED  TO 

SHOAV  THEIR  RELATION  TO  THE  VAGINAL  OUTLET, 

WITH  REFERENCE  TO  EPISIOTO:\IY  INCISIONS 


U\|eK3  Tr^n^u/ar  l.is'vnet^t'   REMevco   (£'Vv;m<j  Musck^ 


E>ult>o  -CAveRNy>tJs 


Vagina!    waI/ 


On  the  left  side  the  superficial  muscles  with  the  superficial  layer 
of  the  triangular  ligament  have  been  removed.  The  well-devel- 
oped deeper  muscles  are  shown  running  into  the  central  tendon. 
On  the  right  side  the  superficial  muscles  are  still  present  and 
dissected  from  the  deeper  layer  only  in  the  ventral  portion  at 
the  pubic  arch.  The  sphincter  ani  is  separated  from  its  sheath 
and  is  shown  in  its  attachment  to  the  central  tendon  and  the 
coccyx.  The  anal  fascia  is  exjiosed  over  the  dorsal  portion  of 
the  levator  ani. 


ETIOLOGY  AND  PREVENTION  OF  LACERATIONS     33 

increased  by  the  passage  of  the  fetal  liead  risks  the  iiipture  of  the 
nmseulai-  tissue  ol*  tlie  amis." 

Peterson  sums  up  the  question  of  episiotomy  as  follows:  ''1. 
Many  cases  in  which  a  tear  of  the  perineum  seems  innninent  escape 
without  any  lesion  whatever  if  the  obstetrician  takes  time  and 
pains  in  the  management  of  the  delivery  of  the  head.  2.  There  are 
two  incisions,  while  a  tear  in  the  perineum  may  be  single.  3.  A  tear 
in  the  perineum,  if  properly  sutured,  unites  as  well  as  the  wounds 
in  episiotomy.  Rui)tures  of  the  perineum  may  involve  the  levator- 
ani  muscle  or  anal  sphincter  and  are  in  a  location  more  difficult  to 
kee])  clean  than  the  posterolateral  wounds  which  involve  no  im- 
portant structure.  Episiotomy  seems  justifiable  only  when  the  oper- 
ation is  certain  to  substitute  two  slight  w^ounds  for  a  serious  peri- 
neal laceration ;  the  less  experienced  the  obstetrician  the  more  like- 
ly is  he  to  x^erform  episiotomy." 

What  does  episiotomy  as  ordinarily  advised  accomplish,  and 
does  it  by  any  chance  prevent  the  injury  of  the  deeper  structures  or 
direct  the  injury  in  the  desired  direction? 

The  operation  is  done  when  the  head  is  beginning  to  distend  the 
vaginal  outlet  excessively.  Surrounding  the  protruding  head  then 
are  the  vaginal-sphincter  muscles,  with  the  inner  edge  of  the  tri- 
angular ligaments  markedly  on  stretch.  The  elastic  central  tendon 
to  which  these  structures  as  w^ell  as  the  transversus  perinei  and 
sphincter  ani  are  attached  is  stretching  across  the  bregma,  which 
is  putting  excessive  strain  on  these  muscle  attachments  and  the  in- 
closing fasciae.  It  is  practically  impossible  to  determine  the  amount 
of  room  required,  and  there  is  no  way  to  check  the  tear  once  started 
in  the  incision  lines  or  to  control  its  direction. 

The  majorit^^  of  the  episiotoni}^  incisions  probably  sever  only  the 
stretched-out  labia  minora  or  fourchette,  and  possibly  the  edge  of 
the  fascia  shelf,  for  it  has  been  estimated  that  the  skin  and  mucous 
membrane,  when  the  perineum  is  in  full  extension,  extend  two  to 
three  centimeters  be^^ond  the  muscle.  When  one  realizes  from  dis- 
sections how  comparatively  deep  the  vaginal  sphincters  are  placed 
beneath  the  labia,  it  is  easy  to  see  that  the  average  incision  would 
not  involve  that  muscle.  If  the  incision  is  only  deep  enough  to  cut 
through  the  superficial  structures  and  Colles's  fascia,  its  location 


34       THE  GYNECOLOGY  OF  OBSTETRICS 

is  of  little  importance,  provided  that  location  does  not  involve  the 
portion  of  the  mucous  membrane  overlying  the  orifice  of  the  gland 
of  Bartholin, which,  if  involved  in  the  resulting  scar,  might  favor  a 
cyst  development. 

To  be  sure  of  saving  the  portion  of  the  perinemn  most  important, 
such  incisions  must  be  carried  through  the  pelvic  floor,  for  a  tear 
that  is  not  going  to  involve  that  structure  should  need  no  episi- 
otomy. 

If  the  incisions  are  placed  laterally  in  no  matter  what  radial 
direction  and  deep  enough  to  accomplish  the  desired  purpose,  they 
are  bound  to  cut  across  some  portion  of  the  muscle  sling  around 
the  vagina.  The  more  downward  and  outward  they  are  from  the 
horizontal  line,  the  less  of  the  total  width  of  this  muscle  sling  they 
separate  on  account  of  the  radiation  at  the  central  tendon  attach- 
ment, but  the  greater  the  chance  of  separating  the  transversus- 
perinei  attachments. 

AYith  the  severance  of  these  muscles,  the  fibers  immediately  re- 
tract, for  they  are  not  sufficiently  attached  to  the  fascia  laj^ers  to 
be  held  thereby. 

The  incision  is  probably  repaired  by  uniting  the  fasciae  and  the 
mucous  membrane,  the  retracted  muscle  being  overlooked.  The 
chances  are  that,  lacking  the  support  of  the  floor,  the  portion  of  the 
pelvic  diaphragm  between  the  vagina  and  the  rectum  has  given 
way,  but  exposes  no  injur}^  superficially. 

The  lateral  attachment  of  the  levator  ani  to  the  sides  of  the  va- 
gina pulls  forward  the  segment  ventral  to  the  incision ;  the  contrac- 
tion of  the  sphincter  ani,  the  dorsal  portion.  The  consequence  is 
that  immediately  following  the  closure  of  the  incisions  where  the 
muscles  have  been  ununited  the  results  look  good,  but  all  the  fac- 
tors are  present  for  the  later  development  of  a  relaxed  outlet. 

If  it  seems  mse  to  guide  the  injury  that  it  is  impossible  to  pre- 
vent, I  prefer  to  incise  the  apex  of  the  stretched-out  fourchette 
through  the  central  tendon  as  far  as  it  appears  necessary.  If  the 
injury  promises  to  be  so  excessive  as  to  involve  the  sphincter,  it  is 
possible  to  direct  the  cut  to  one  side  or  the  other,  though  such  pro- 
cedure is  almost  out  of  the  possibility  of  requirement,  as  careful 
delivery  will  save  the  sphincter  almost  invariably.  Injury  of  the 


i^Tioi.odv  Axi)  nn<:\'Kx^n()X  ok  lackuatioxs   :]5 

spliiiictci-  is  almost  without  (lucstioii  tlic  result  of  too  hasty  de- 
livci'W  though  thci-c  ai'c  occasioiuill)'  suhjccts  where  the  tissues 
seem  to  melt  a\\a>-  uudei-  pi-acticall)'  no  strain. 

I  prefei-  this  median  incision,  knowin.i;-  that,  witli  the  method  of 
i-e|)air  advised,  it  is  ])ossihle  in  the  majority  of  eases  to  ^-et  fi,-ood 
results.  With  a  direet  median  ineisiou  tliere  is  no  danger  of  indi- 
vidual nmsele  i-etraetion,  foi-  at  this  point  the  fasciae  and  muscles 
are  intimatel_\'  associate(l.  it  is 
also  easy  to  follow  up  the  exten- 
sion of  the  injury  if  it  has  gone 
beyond  the  range  of  the  incision. 
There  is  then  also  no  unsuspect- 
ed subnuieous  tear  overlooked, 
and,  moreover,  it  is  possible  to 
adjust  the  size  of  the  incision  to 
the  size  of  the  head. 

Tn  cases  in  which  the  dia- 
phragm has  given  way  beneath 
the  uninjured  mucous  mem- 
l)rane,  and  even  beneath  tlie 
central  tendon,  some  authorities 
advise  cutting  through  the 
bridge  of  tissue  so  as  to  be  able 
to  approximate  the  retracted 
structures. 

Tf,  according  to  Hartmann, 
"  in  spite  of  all  prevention  the 


This  patient  has  been  twice  coufiueil.  In 
neither  case  was  there  any  tearing  of  the 
mucous  membrane.  The  degree  of  relaxation 
is  very  marked,  but  on  the  ventral  wall  the 
rugae  are  still  prominent.  If  a  patient  is 
confined  in  the  lateral  posture,  such  an  in- 
juiy  to  the  levator  ani  may  be  more  readily 
observed  during  its  occurrence. 


]ierineum  is  torn,  the  rupture  is 
lateral  always,  the  posterior  column  of  the  vagina,  fil)rous  and  re- 
sistant, remaining  intact.  The  vagina,  skin  and  vulvar  constrictor 
being  torn  tlirough,  on  se])arating  them,  we  get  a  lozenge-shaped 
wound  which  left  to  itself  to  cicatrize  results  in  a  ]ierineum  which 
no  longer  plays  its  role  as  a  supporting  agent." 

It  is  true  that  in  the  majority  of  injuries  the  tear  is  lateral,  not, 
however,  because  of  the  resistant  dorsal  vaginal  wall. 

The  greater  numlier  of  tears  are  unilateral,  with  probably  a 
larger  per  cent  on  the  left,  but  wlietlier  this  is  due  to  the  preponder- 


36 


THE  GYNECOLOGY  OF  OBSTETRICS 


ance  of  left  presentations,  as  claimed  by  some  writers,  is  question- 
able. It  is  probabl}^  true  that  some  of  the  tears  are  caused  by  the  de- 
livery of  the  shoulders  rather  than  the  he^d;  or,  at  least,  we  can 
perhaps  more  safely  say  the  shoulder  deliveiy  increases  the  degree 
of  injury,  for  it  is  impossible  to  determine  the  extent  of  the  tear  re- 
sulting from  the  birth  of  the  head,  especially  where  the  central  ten- 
don has  not  been  excessively  injured.  The  injuries  produced  by  the 

shoulders  are  more  often  than 
not  due  to  the  greater  haste  of 
the  obstetrician  in  their  deliver}?- 
or  are  a  result  of  the  method 
used  to  extract  the  arm.  If  the 
central  tendon  only  is  involved, 
and  the  structures  are  of  equal 
strength  on  either  side,  the  tear 
is  alwa^^s  in  the  median  line,  for 
that  is  the  point  at  the  apex,  as 
it  were,  where  the  greatest  ten- 
sion comes.  If  the  central  ten- 
don is  not  involved,  but  tearing 
of  the  pelvic  diaphragm  occurs, 
it  is  always  situated  laterally. 

Tears  of  the  vaginal  mucous 
membrane  may  occur  in  any  di- 
rection if  the  stretching  is  too 
severe,  but  the  tear  in  the  dia- 
phragm always  runs  to  the  side 
in  the  plane  of  the  levator  ani, 
and  this  is  accounted  tor  by  the  anatomical  relations.  A  combina- 
tion tear  involving  both  the  floor  and  diaphragm  is  a  "  Y  "-shaped 
injury  if  both  sides  of  the  vagina  are  involved,  though  only  one 
arm  of  the  "  Y  "  is  present  when  the  injury  is  not  bilateral.  We 
must  bear  in  mind  that  if  the  diaphragm  is  injured,  no  matter  in 
what  direction  the  mucous-membrane  tear  occurs,  we  can  demon- 
strate the  defect  by  careful  palpation.  The  very  presence  of  a  lat- 
eral tear  running  from  inside  the  central  tendon  indicates  a  rup- 
tured pelvic  diaphragm. 


A  relaxed  vaginal  outlet  in  which  the  cen- 
tral tendon  and  median  raphae  have  not  been 
injured.  The  injury  to  the  levator  ani  has 
permitted  the  development  of  a  rectocele. 
This  patient  had  had  an  abdominal  oper- 
ation to  correct  a  retrodisplacement,  but  with 
no  improvement  to  her  symptoms.  A  perine- 
orrhaphy cleared  up  the  physical  condition. 


KTIOLOUY  AXI)  PRKVKXTIOX  OF  LAC'KHATIOXS     37 

Upon  the  I'datioii  ot*  tlic  s(',<;-ni('iits  of  the  Icvatoi'  aiii  to  each 
otlici*  and  upon  tlicir  attaclmiciits  in  tlic  median  line  depends  tlie 
C'oui'se  of  injury  to  llic  pcKic  diaplii'a,i;in.  'riic  Ncnti'a!  se<;'nient  of 
the  muscle,  hy  its  linn  attachment  to  the  si(h'S  of  the  vaj^ina  and  its 
fascia  layei-s  attached  under  tlie  pul)ic  ai'cli,  together  witli  the  firm 
triangular  ligaments, -prevents  any  chance  foi-  much  freedom  of 
play,  and  practically  fixes  the  ventral  and  side  walls  of  the  vagina. 
AVhen  the  excessive  dilatation  comes,  the  picssure  is  conseciueiitly 
exerted  most  markedly  in  stretching  out  the  parts  dorsal  to  these 
structures.  The  dorsal  edge  of  the  triangular  ligament,  which  has 
heen  called  the  '*  ischioi)erine,al  "  ligament,  for  all  ))ractical  pur- 
poses may  he  considei'ed  as  defining  the  fixed  portion  of  the  pelvic 
diaphragm  fiom  the  more  readily  distensible  portion  dorsally. 

The  pressure  of  the  child  as  it  comes  from  the  hollow  of  the  sa- 
crum under  the  pubic  arch  is  directed,  against  the  dorsal  two-thirds 
of  the  pelvic  diaphragm.  The  portion  behind  the  rectum,  on  ac- 
count of  its  protection  b}^  the  two  firm  fascia  layers  and  the  elas- 
ticity of  the  rectum  itself,  bears  the  strain  best,  and  is  also  well 
])rotected  from  sudden  force  by  the  central  portion  of  the  muscle 
with  its  fascia  reflections  situated  between  the  vagina  and  the  rec- 
tum. Xaturally,  this  portion  between  the  vagina  and  the  rectum, 
w  liicli  is  })ractically  a  separate  segment,  is  the  one  first  to  give  way 
to  dilating  forces.  Having  given  way,  it  is  on  account  of  the  firm 
fixation  of  the  vaginal  canal  ventrally  and  laterally  and  the  greater 
elasticity  of  the  dorsal  segment  that  the  tear  extends  up  the  vagina 
in  the  plane  paralleling  the  segment  division.  This  same  injury  can 
happen  without  any  superficial  tearing  in  cases  where  the  disten- 
sibility  of  the  vaginal  canal  is  possible  on  account  of  well-defined 
rugae.  As  a  rule,  in  such  subcutaneous  ruptures,  the  central  tendon 
is  elastic  enough  to  stretch  Avithout  tearing.  Thus,  the  most  careful 
palpation  is  necessary  to  define  such  an  injury,  as  superficially 
there  is  no  evidence. 

Lacerations  of  the  cervix  are  even  more  frequent  than  perineal 
injuries.  Some  men  write  of  jDhysiological  lacerations  of  the  cervix, 
thus  acknowledging  the  fact  that  in  practically  every  case  we  get 
some  degree  of  injury.  Many  are  shallow  enough  to  involve  the  mu- 
cous membrane  only,  and  these  naturally  are  of  little  pathological 


THE  GYNECOLOGY  OF  OBSTETRICS 


consequence.  What  concerns  us  in  the  later  plastic  work  is  the  tear 
that  is  deep  enongh  to  injure  the  circular  muscle  fibers,  and  which 
in  the  process  of  healing  gives  the  round-cell  infiltration  and  later 
the  scar-tissue  formation  in  the  angle  of  the  wound. 

It  is  true  that  we  may  prevent  the  formation  of  extensive  injury 
by  avoiding  the  too  early  application  of  forceps  or  too  strenuous 
forcil)le  dilatation. 

The  more  severe  cervical  injuries  probably  occur  from  forceps 

deliveries,  and  especially  in 
those  cases  where  the  undi- 
lated  ring  is  carried  down 
Avith  the  head,  pinching  the 
ventral  lip  between  the  head 
and  the  pubes.  It  is  probabh' 
true,  too,  that  the  shoulders 
may  produce  injuries  or  in- 
crease those  alread}^  pro- 
duced by  the  head  where  ex- 
traction is  too  rapid. 

The  text-book  advice  is  to 
leave  cervical  injuries  alone 
unless  the  need  of  control- 
ling hemorrhage  arises.  The 
difficulty  of  the  work,  the  in- 
creased risk  of  infection,  the 
rapid  involution  of  the  tis- 
sues in  the  first  days,  which 
tends  to  leave  the  stitches 
too  slack  to  approximate  the  torn  edges,  and,  finally,  the  fact  that 
the  majority  of  tears  heal  kindly  without  intervention,  give  us  the 
authority  for  this  stand.  However,  a  large  number  of  cervical  tears 
do  not  thus  heal  by  first  intention,  and  the  formation  of  scar  tissue, 
with  or  without  the  turning  out  of  the  cervical  mucous  membrane, 
gives  rise  to  the  secondary  symptoms.  There  can  be  no  doubt  that 
many  miscarriages  are  due  to  the  persisting  deep  clefts  in  the  cer- 
vical tissue,  even  when  not  associated  with  endocervicitis,  which 
alone  is  enough  to  prevent  pregnancy  or  favor  miscarriage. 


Lacerated  cervix.  The  greater  injury  is  on  the 

left  side,  extending  as  high  as  the  internal  os. 

This  patient  miscarried  twice  before  operation, 

but  since  then  has  been  confined  at  term. 


^7l^l()IJ)(i^'  AXI)  IMJKN'KXTIOX  OF  LACERATIONS     :;9 

The  usual  trcatincut  of  the  pai'luriciit  woman  lias  kept  her  lii-ni- 
ly  baiula^-ed  and  lyin.ii,-  on  liei-  hack.  During  the  (ii-st  twenty-four 
liours  after  eonrnieuuMit,  a  siiu.i;ly  littin.ii,-  hinder  with  a  fii-ni  pad,  so 
placed  as  to  keep  the  fundus  against  the  puhes,  favors  tlie  contrac- 
tion of  the  uterus  and  the  prevention  of  liemorrha^-e.  After  tlie  dan- 
ger of  i-elaxation  has- passed,  anythin,!;-  hut  a  loose  binder  is  not 
only  usek'ss,  ])ut  may  be  injuri<ms.  A  lirni  ])inder  lias  little  or  no 
value  in  favoring  the  popular  desire  for  '^  shape  " — a  muscle  done 
up  in  a  splint  gains  nothing  in  sti-ength,  but  judicious  use  of  the 
abdominal  muscles  is  what  brings  l)ack  tone  to  the  stretched  ante- 
rioi-  wall.  A  linn  l)inder  does  luirm  liy  forcing  the  uterus  into  the 
])elvis  and  thus  stretching  the  lower  uterine  supports;  or,  if  the 
supports  are  resistant,  it  tends  to  evert  the  injured  cervical  lips 
and  prevent  primary  union.  It  seems  reasonable  to  lay  the  persis- 
tence of  many  a  cervical  injury  to  pressure  thus  applied,  and  the 
same  applies  in  a  lesser  degree  to  the  perineum. 

The  injurious  effects  do  not  stop  here,  however,  for  the  pressure 
combined  with  too  prolonged  dorsal  decubitus  favors  the  sinking  of 
the  uterus  in  the  pelvis,  and  thus  its  later  retrodisplacement,  with 
a  permanent  elongation  of  the  ligaments. 

In  a  case  complicated  by  separation  of  the  recti  muscles,  support 
of  the  abdominal  wall  is  necessary,  but  not  to  the  point  of  produc- 
ing pressure  sufficient  to  result  imfavorably  to  the  cervix  and 
uterus. 


PATHOLOGY  OF  THE  CERVIX 

THE  pathological  conditions  of  the  cervix  from  the  stand- 
point of  etiology  may  be  classified  under  two  heads — the 
conditions  resulting  from  infections,  and  those  that  are  me- 
chanical. The  malignant  growths  are  processes  superim- 
jDosed  on  the  induced  pathology  that  results  from  one  of  these  etio- 
logical factors,  most  frequently  the  mechanical. 

The  mechanical  factors  are  by  far  the  more  numerous,  including 
not  only  the  direct  conditions  resulting  from  injuries  of  childbirth 
and  instrumental  dilatation,  but  the  indirect  ones,  such  as  cervical 
inflammation  and  hypertrophy  secondary  to  the  relaxed  vaginal 
outlet. 

Cervical  infections  are  not  common,  and  are  chiefly  due  to  the 
venereal  factors  of  gonorrhea,  syphilis,  and  chancroid. 

Practically,  the  only  acute  cervical  inflammation  of  moment  clin- 
ically is  the  gonorrheal,  unless  the  inflammation  has  been  the  result 
of  germ  inoculation  by  instrumentation,  in  which  case  the  inflam- 
mation is  not  confined  to  the  cervix.  Consideration  of  inflamma- 
tions having  their  origin  above  the  cervix,  even  if  associated  with 
marked  cervical  inflammation,  is  out  of  place  here. 

Acute  gonorrhea  may  localize  itself  in  the  cervix  without  extend- 
ing higher,  and  it  is  then  evidenced  by  a  soft,  congested  cervix  with 
swollen,  puffed-out  mucous  membrane,  covered  by  yellow,  often 
greenish,  discharge,  and  often  with  spots  of  erosion  on  the  surface. 
With  this,  as  a  rule,  is  associated  a  congested  vagina,  a  urethral 
discharge,  and  the  "  gonorrheal  maculae,"  as  the  reddened  orifices 
of  the  ducts  of  the  glands  of  Bartholin  have  been  called — so  called 
because  that  appearance  is  practically  always  associated  with  gon- 
orrhea, on  account  of  the  susceptibility  of  the  glands  to  that  infec- 
tion. It  must  be  remembered,  however,  that  one  is  not  justified  in 
making  a  diagnosis  of  gonorrhea  from  that  finding  alone,  since 
other  infections,  and  occasionally  a  hyperfunction,  Avill  cause  a  red- 
dened orifice.  The  microscope  will  confirm  the  diagnosis,  although 


PATJl()LU(iY  OK  THE  C"KR\'IX  41 

it'  the  coiulitioii  lias  become  less  acute  it  may  )k'  difficult  to  find  the 
diplococcus  of  Neisser.  The  presence  of  many  pus  cells  in  the  dis- 
charge when  no  germs  are  deinoiistrabk^  is  always  a  (iiiding  suspi- 
cious of  gonorrheal  infection. 

In  the  chronic  infections  of  the  cervix  (aside  from  tuberculosis 
and  syi)hilis)  the  gono- 
coccus  plays  an  impor- 
tant part,  the  germs 
frequently  remaining  in 
the  depths  of  the  glands 
ready  to  be  stirred  up 
by  any  mechanical  in- 
terference, as  is  the  case 
with  Littre's  follicles  in 
the  urethra  or  with  the 
glands  of  Bartholin  in 
the  vulva.  The  enlarged, 
congested  cervix,  the 
increased  glandular  se- 
cretion, and  possibly 
some  cystic  glands  are 
practically  the  only  im- 
portant signs. 

Another  chronic  in- 
fection that  has  all  the 
physical  signs  of  an 
acute  process,  yet  is  al- 
ways of  chronic  dura- 
tion and  \\T.th  few  acute 
symptoms,  is  caused  by 


Section  of  tissue  removed  by  the  curette  from  the 
cervix  for  diagnosis.  The  glandular  proliferation  pres- 
ent is  characteristic  of  any  inflammatory  process.  In 
the  upper  right-hand  portion  of  the  illustration  is  an 
area  shovring  marked  round-cell  infiltration  surrounding 
an  area  of  cell  necrosis.  Bordering  the  necrotic  area  are 
a  number  of  giant  cells.  These  are  the  elements  that  are 
diagnostic  of  a  tuberculous  process — a  condition  not 
often   found  in   the  cervix  as   a  primary  involvement. 


the  diphtheroid  bacillus 
This  infection,  involving  the  cervix  alone,  l3ut  more  frequently  ex- 
tending over  the  whole  vagina,  is  usually  found  in  young  unmar- 
ried women.  The  muCous  membranes  have  all  the  appearance  of  an 
acute  inflammation,  and  are  covered  with  a  creamy,  yello^\ish.  dis- 
charge. The  diphtheroid  bacillus  can  be  grown  usually  in  pure 
culture,  not  only  from  the  discharge,  but  from  the  urine.  From  the 


42 


THE  GYNECOLOGY  OF  OBSTETRICS 


iieiy  ai^pearance  of  the  mucous  membranes  one  could  readily  sup- 
pose a  streptococci  infection,  and  the  comparative  lack  of  all  symp- 
toms bej^ond  the  discharge  makes  an  unusual  combination. 

Rosenow's  theor}'  of  germ  convertibilit}^,  in  which  the  type  and 
virulence  are  controlled  by  the  location  of  the  primary  focus,  would 
possibly  place  this  diphtheroid  bacillus  as  a  modified  streptococcus. 


This  higher  magJiification  of  the  preceding  slide  is  taken  at  the 
edge  of  one  of  the  tubercles.  In  the  upper  corner  is  the  beginning 
of  the  necrotic  area;  in  the  center  of  the  illustration  the  layer  of 
typical  giant  cells,  and  below  these  the  round-cell  infiltration;  thus 
showing  the  characteristic  formation  of  a  tuberculous  process.  The 
giant  cells  with  their  nuclei  arranged  around  the  periphery  more 
or  less  in  the  shape  of  a  horseshoe  are  typical  of  tuberculosis.  Sur- 
rounding these  are  the  distinct  connective-tissue  proliferations  op- 
posite the  area  of  necrosed  young  mesoblastic  cells — findings  also 
characteristic  of  the  same  disease. 

The  most  characteristic  features  of  the  process  are  the  severity 
of  the  signs,  the  absence  of  acute  symptoms,  and  the  marked  re- 
sistance to  the  usual  methods  of  cervical  and  vaginal  treatment. 
The  most  prompt  improvement  has  come  from  the  use  of  the  basic 
fuchsin  1-1000  as  an  application,  yeast  tampons,  and  vaccines. 

Primarv  tuberculosis  of  tlie  genital  tract  is  rare,  and  most  ob- 


i^vTiioiJXiV  OK  'niK  CKin'ix  43 

servers  coiisidef  that  the  .i-i'eatei-  |)erceiita,i2,-e  of  cases  of  ceivical 
tuher('uh)sis  have  theii-  ()l•i,^•ill  lii,i;lier  in  the  tract  than  the  cervix, 
thoii.uii  ()thei-s  chiiiu  that  at  aiitopsx'  the  ,<;-i-eater  t're(|iieiic\-  of  hodx' 
iii\()l\(Miient  oNCi-  cei-vical  is  (hie  to  the  .i-feater  ease  of  diaj^'iiosis  of 
the  cerN-ical  condition  and  its  sahscMjiient  removal  It  is  ])robably 
line  that  some  cases  of  cervical  involvement  are  operated  upon 
when  no  true  diai^'iiosis  has  heeii  made.  It  is  hardly  necessary  to 
consider  in  this  chapter  the  minutiae  of  cervical  tul)erciilosis,  for 
the  condition  has  the 
sa  me  cliaracteristics 
here  as  elsewhere ;  hut 
it  is  necessary  to  em- 
phasize the  fact  that 
primary  involvement 
of  the  cervix  is  rare, 
and  that  the  probabil- 
ity is  that  tlie  body 
is  also  involved.  But 
the  body  involvement 
would  place  the  con- 
sideration of  the  condi- 
tion beyond  the  scope 
of  this  work.  Micro- 
scopical examination 
will  confirm  the  diag- 
nosis   and    emphasize 

the   SUroical  treatment     *'^'^  early  case  of  epithelioma  of  the  cervix.   The  pene- 

if  its  limitation  to  the 
pelvis  is  certain. 

Chancroidal  ulcerations  are  usually  multiple  and  associated  with 
similar  conditions  on  the  vulva.  The  greater  amount  of  local  in- 
flammation, the  increased  discharge,  the  more  marked  sensation, 
with  the  lack  of  general  manifestations,  distinguish  the  condition 
from  syphilis.  Here,  as  elsewhere,  a  positive  diagnosis  cannot  be 
made  on  the  clinical  hndings  alone.  The  microscopic  demonstration 
of  spirochetes  will  designate  lues, but  clinically  sixty  or  ninety  days 
must  elapse  before  one  can  be  positive  of  a  local  infection  only. 


tration   of   the   squamous   cell   masses   into   the    stroma, 

gradually  involving   the   normal    covering    of   the  cervix. 

is  typical  of  a  malignant  ulcer. 


44 


THE  GYNECOLOGY  OF  OBSTETRICS 


Syphilis  often  shows  itself  in  the  primary  as  well  as  the  second- 
ary and  tertiary  stages  on  and  in  the  cervix.  Though  the  initial 
lesion  is  frequently  located  upon  the  squamous  nmcous  membrane 
of  the  cervix,  it  is  often  overlooked  because  it  does  not  always  ap- 
pear as  the  classical  chancre ;  in  fact,  more  often  we  have  a  local- 
ized spot  of  hypertrophy  without  the  loss  of  substance  of  ulcer- 
ation. Consequently, 
the  diagnosis  of  syph- 
ilis in  the  female  is 
and  should  be  made 
from  the  secondaries, 
although  a  follicular 
vulvitis,  if  associated 
with  a  suspicious  cer- 
vix, or  even  if  occur- 
ring as  an  entity,  is 
exceedingly  sugges- 
tive of  specific  infec- 
tion. 

In  the  secondaries, 
on  account  of  the  lack 
of  symptoms,  mucous 
patches  on  the  vagi- 
nal walls  and  on  the 

A  section  from  the  cervix  at  the  edge  of  an  cjiithelioma-  Cervix     are     probably 
tous  ulcer,  or  so-called  ' '  chancroid  der  portio, ' '  removed  i        -i    j       j.     -i        mi,    • 

for  diagnosis.  The  stratified  squamous  epithelial  covering  CieteCieCl.       ineil 

of  the  cervix  is  intact  in  the  upper  portion,  but  over  the  principal    importance 
ulcer  area  has  been  replaced  by  masses  of  characteristic  ,  _,     , 

squamous  epithelial  cells  which  groAV  into  the  stroma  in  WOUiQ     DC     aS     a     COU- 

finger-like  projections.   These  epithelioma  areas   are  sur-  fimiatory   sigU   in   di- 
rounded  by  inflammatory  infiltration. 

agnosis. 
The  tertiary  involvement  of  the  cervix  is  not  infrequently  un- 
recog<nized,  especially  as  this  condition  has  its  expression  in  a 
marked  hypertrophy  with  many  and  often  exaggerated  cyst  for- 
mations. Such  a  possibility  must  be  borne  in  mind,  for  the  local 
operative  work  w^ill  not  accomplish  anything  toward  a  permanent 
correction,  since  the  condition  will  rapidly  recur  if  no  systemic 
treatment  is  inaugurated.  The  general  manifestations  at  this  stage 


PATII()L()(i^'  OK  ^rilK  CKRVIX 

ft 

'2 1,'», 


45 


arc  always  pi-eseiit  and  will 
coiififm  tlie  diagnosis.  Such 
s\|)liilili('  liyi)(M'tro])liy  is  or- 
(liiinril)'  supcfiiiiposccl  on  a 
('(M-vix  injui-('(l  at  ciiildhii'tli. 
In  the  cervix  two  types  of 
cancerous  formation  occur 
— the  epithelioma  and  tlie 
cai-cinonia.  The  epithelioma 
with  its  usual  microscopical 
characteristics  appears  first, 
of  course,  on  the  surface 
epithelium,    and   practically 

This  section  of  a  ,Ka  Uuu  ol   .cr^  :.aU.,,Ula.luMHu      ^IwayS    in    WOUieU    who    have 

sliows  the  cells  arranged  m  ' '  whirls,       the  so-  ■' 

called   "pearls"   of   the   squamous-cell   growth,      had  injuries  from  childbirth 

or  mechanical  dilatation.  More  recent  observations  have  shown 
that  tlie  tumor  does  not  begin  on  the  site  of  the  injur}^  with  its  scar- 
tissue  formation,  but  on  the  ventral  or  dorsal  lip,  which  often 
shows  no  defect.   The 


history  of  the  preced- 
ing injuries  is  always 
present. 

Rodman,  of  Phila- 
delphia, recently  made 
the  positive  statement 
that  lacerations  of  the 
cervix  should  be  re- 
])aired,for,  in  his  opin- 
ion, it  has  been  clearly 
shown  that  nearly  all 
cervical      carcinomata 


^*fr 


• 
#        * 


■•   t 


A  section  from  a  squamous-cell  carcinoma  of  the  cervix, 
of  interest  mainly  because  the  marked  enlargement  of 
the  individual  cells  shows  well  the  extraordinary  poly- 
morphous character  of  cancer  cells.  Some  of  the  stages 
of  cell  division  are  also  represented. 


46 


THE  GYNECOLOGY  OF  OBSTETRICS 


follow  lacerations, 
and  that  nnmarried 
and  unfruitful  wom- 
en, while  quite  as 
frequentl}^  suffering 
from  corporeal  can- 
cer as  multiparae, 
are  exempt  from  the 
cervical  variety. 

While  not  over- 
looking the  possible 
parasitic  origin  of 
cancer,  it  is  clinical- 
ly evident  that  can- 
cer formation  has 
its  origin  always  in 
locations  where  in- 
creased congestion 
due  to  irritation  is 


life  .     

A    section    sliovviiig    exteiibive    iii\  oheiueiit    ui'    llu 
caucer   structure.   The   normal  cervical   elements 
completely  replaced. 


A  more  highly  magnified  section  of  cancer  of  the  cervix.  The 
two  gland  sections  represented  show  a  piling  up  of  the  epithe- 
lial cells.  The  basement  membrane  is  intact,  and  the  epithelial 
piling  is  not  as  irregular  as  usual.  The  diagnosis  of  malig- 
nancy is  founded  upon  the  metamorphous  character  of  the 
cells  and  the  complete  obstruction  of  the  gland  lumen. 

present.  It  is  Bos- 
si's  contention  that 
cancer  is  solely  of 
histological  origin, 
and  in  most  cases 
begins  in  lesions 
that  are  benign ; 
and  that  the  irrita- 
tion is  the  indirect 
cause  of  the  malig- 
nant formation  by 
producing  an  in- 
creased circulation. 
The  increase  is  due 
to  the  formation  of 
new  vessels  or  the 
enlargement  of  the 
old. 


cervix    by 
are   almost 


PATIIOLOOV  OK  TllK  CKin'lX  47 

TIio  extra-c'oiitiiiuous  blood  supjtly,  piohably  by  some  ch'Miiical 
alteration,  stiimilatcs  the  cpitliclial  cells  of  glandular  structure  to 
overg-rowth  and  abiioi-iiial  cell  di\ision.  These  epithelial  cells  be- 
come eiiibr>()uic  in  charactei",  and,  lik<'  all  eiiibrNonic  cells,  have 
^•i-eater  power  of  reproduction  and  t;ro\v  at  the  expense  of  the  nor- 
mal elements. 

Most  pathologists  l)elieve  tJiat  the  cancer  cell  is  a  "  weak  cell" 
and  less  resistant  to  destructive  agents  than  the  normal  tissue  ele- 
ments. For  this  reason  radiotherapy,  either  witii  the  X-ray,  radi- 
mn,  or  mesothori- 
um,  has  the  ])()wer 
to  injure  the  can- 
cer cell  more  rajnd- 
ly  than  the  normal 
tissue.  The  cancer 
cell  thus  can  be 
considered  as  hav- 
ing a  greater  ac- 
tivity of  growth, 
which  is  a  positive 
powder,  but  as  lack- 
ing tlie  negative 
faculty  of  resist- 
ance, Avhich  is  a 
(juality  of  normal 
tissue. 

Theoretically,  it 
would  be  more  nat- 
ural to  expect  the  malignant  growth  to  have  its  origin  in  the  ven- 
tral oi-  dorsal  lip  rather  than  at  the  site  of  the  tear,  for  the  normal 
1)1()0(I  supply  runs  around  the  cervix  from  its  lateral  origin,  and 
the  scar-tissue  contraction  at  the  angles  of  the  tear  w^ould  decrease 
the  supply  there,  but  tend  to  increase  it  in  the  normal  tissue 
through  interference  with  the  return  flow\  It  w^ould  also  be  more 
natural  to  expect  the  stimulation  by  the  circulation,  with  the  in- 
creased growth  in  the  cells  that  are  free  from  the  cicatricial  tissue 
found  around  the  angles  of  the  tears.  The  much  more  frecpient  per- 


A  section  of  an  adenocarcinoma  of  the  cervix.  The  more 
marked  stroma,  with  the  proportionally  less  heaping  of  the 
the  epithelial  cells,  indicates  a  hard,  slow-growing  tumor. 
The  malignancy  is  marked  by  the  usual  characteristics.  Such 
a  growth,  while  relatively  common  in  the  uterine  body,  is 
comparatively  rare  in  the  cervix. 


48       THE  GYNECOLOGY  OF  OBSTETRICS 

sistence  of  the  lateral  clefts  in  injuries  of  the  cervix  over  those  in 
the  ventral  and  dorsal  lips  tends  to  make  us  overlook  the  fact  that 
injuries  do  occur  and  persist  as  well  in  the  median  line  of  the 
cervix,  and  in  those  cases  we  should  rather  expect  the  degeneration 
to  begin  laterally. 

The  early  manifestations  of  the  disease  differ  little  in  appear- 
ance and  character  from  Nabothian  cyst  formation,  but  the  greater 
induration,  the  solid  and  less  translucent  character,  the  single  nod- 
ule, the  location  in  the 


ventral    or    dorsal    lip, 
usually    at   the   mucous 
jmicture,  tend  to  aid  in 
the  differentiation,  and, 
fortunatel}^,   in   the   mi- 
croscopical examination 
lies  our  method  of  posi- 
tive  diagnosis.  It  is  in 
this  stage  that  its  recog- 
nition   is    difficult,    and 
that  its  removal  by  high 
amputation,   as   advised 
by  some  men,  by  actual 
cautery,   or  by  carbon- 
dioxide  freezing  is  pos- 
sible.  Later  it   is   only 
from     more      extensive 
procedures,  such  as  hys- 
terectomy, that  we  can 
expect  a  radical  cure.  In 
the  late  stages,  when  operation  is  impossible,  the  only  hope  lies  in 
the  cautery,  the  X-ray,  or  the  newer  applications,  such  as  meso- 
thorium.  That  the  recent  excessive  enthusiasm  over  radium  in  the 
treatment  of  malignancy  is  not  well  founded  is  the  opinion  of  men 
most  qualified  to  pass  upon  the  subject. 

In  the  beginning  of  the  growth  the  only  symptom  present  may 
be  increased  leucorrheal  discharge.  By  the  time  blood-streaked  mu- 
cus and  bladder  irritation  and  pain  have  supervened  ulceration  has 


A  highly  magnified  reproduction  of  a  portion  of  the 
preceding  section,  showing  a  single  gland.  The  char- 
acteristics of  malignancy  are  well  shown — the  meta- 
morphous  character  of  the  cells,  the  irregular  heaping, 
with  the  destruction  of  the  basement  membrane. 


I>ATTK)L()(JV  OF  TlIK  (M^RVIX 


49 


()('cuii(mK  and  the  a<l,j()iiiiiiK  striictiircs  may  Jiave  heconic  involved; 
l)iit,  fortuiiMtcl.w  cN'cii  a  late-disc'overod  cpitlielioiua  is  slow  in 
,i>laiidiilar  cxtciision,  and  thus  offers  greater  hope  for  complete  ex- 
tii-|)ati()ii. 

'i'lic  cai-ciiiomatous  type  havini;-  its  origin  on  tlie  surface  of  the 
cer\'ical    canal    mucous    meinhrane,    oi'    witliin    the    g'lands    them- 


A  malignant  tumor  of  the  cervix  in  which  the  growth  has  pene- 
trated deeply  into  the  tissues.  Some  of  the  finger-like  projec- 
tions are  here  shown  in  cross-sections.  Not  only  the  squamous 
cell,  but  also  the  cylindrical  growths,  tend  to  this  arrange- 
ment. This  section  is  from  glandular  carcinoma,  judging  by 
the  character  of  the  cells  and  the  fact  that  the  masses  of  cells 
are  growing  toward  their  center. 

selves,  is  more  rapid  in  growth,  especially  in  younger  individu- 
als, and,  if  not  accompanied  by  ulceration,  may  progress  within 
the  canal  to  serious  involvement  without  producing  sufficient 
symptoms  to  cause  its  recognition.  It  will,  on  account  of  its  mor- 
phology and  situation,  involve  the  lymphatics  earlier  than  the 
epithelioma. 

Cervical   curettage   and  microscopical  examination   aid  in  the 


50 


THE  GYNECOLOGY  OF  OBSTETRICS 


earl}^  recognition,  and,  if  malignancy  is  proven,  should  be  followed 
immediately  b}^  radical  treatment. 

Cases  have  been  reported  in  which  the  clinical  symptoms  pointed 
toM^ard  malignancy,  while  the  tissue  examination  had  negative  find- 
ings; but,  as  Dr.  Rodman,  of  Philadelphia,  in  reporting  a  case  of 
lip  ulcer  excised  as  possibly  malignant  but  returned  as  benign  by 
the  pathologists,  says,  "  The  patient  is  happy  that  he  hadn't  can- 
cer, and  I  am  not  unhappy  that  it  wasi  prevented.  Instead  of  cha- 


Metfistatic  crarciiiuiiia  of  a  lymph  gland.  Characteristic 
nests  of  epithelial  cells  are  present  throughout  the  entire 
gland.  This  section  of  a  normal-sized  lymph  gland,  about 
an  eighth  of  an  inch  in  diameter,  well  illustrates  the  im- 
possibility of  complete  gland  extirpation  in  cases  of  can- 
cer of  the  uterus.  It  confirms  the  present  opinion  that  the 
extensive  gland  dissection  with  its  high  primary  mortality 
is  not  justifiable.  A  carcinoma  already  beyond  the  cervix 
may  have  many  such  metastases. 


grin,  when  such  reports  are  received  from  the  laboratory,  there  is 
cause  for  exultation.  The  more  of  them  the  better. ' ' 

It  is  the  belief  of  some  surgeons  that  curettage  or  tissue  removal 
done  for  examination  purposes  only  hastens  the  spread  of  the 
disease.  In  no  case  must  we  disregard  clinical  findings  for  those 
of  the  laboratory,  since  it  is  impossible  for  any  examination  to  be 
exhaustive,  and  the  malignant  structure  may  be  overlooked  by  sur- 
geon or  pathologist.  It  is  better  to  do  the  radical  work  if  the  clin- 


PATIIOr.OGY  OF  THE  CERVIX  51 

ical  syinptoins  are  suspicious,  even  if  the  pathological  report  is 
iu\t;ative.  If  i)()sitive  evidence  is  obtained,  no  delay  is  justified,  and 
the  ([uestion  of  exten(lin,i!,'  the  infection,  if  an  innnediate  operation 
is  done,  can  hai-dly  enter  into  the  discussion. 

Fibroids  of  the  cervix  are  comparatively  common.  Sarcomas  oc- 
cur, ))ut  are  rare.  Neither  condition  conies  within  the  scope  of  our 
]) resent  i)urpose.  These  are  mentioned  only  to  emphasize  the  possi- 
bilities. 

(Miorioepithelionia  of  the  cervix  or  vaginal  canal  is  a  possibility, 
hut  it  always  has  as  its  forerunner  a  complete  or  an  incomplete 
{jregnancy,  a  i)ervert- 
ed  pregnancy,  such  as 
in  hydatid  mole,  or  a 
teratoma. 

When  cliorioepithe- 
lionia  occurs  in  the  va- 
gina, it  is  most  often 
situated  on  the  dorsal 
wall  a  little  beloAv  the 
])oint  opposite  the  cer- 
vical OS.  A  recent  case 
in  my  hands  presented 
the  appearance  of  an 
irregularly  punched- 
out  ulcer  about  one- 
half  inch  in  diameter, 
the  edges  undermined, 
the  base  seemingly  an 
attached  blood-clot.  Profuse  bleeding  had  taken  place  from  the  ul- 
cerated area  at  the  time  of  an  abortion  of  a  tAvo-month  pregnancy, 
and  had  been  controlled  by  the  physician  in  charge  only  by  suture 
and  packing. 

Every  chronic  congestion  of  the  cervix  and  cervical  canal  has  a 
mechanical  basis  for  its  presence.  It  may  be  an  injury  from  child- 
birth to  the  cervix  itself  or  to  the  perineum,  and  this  is  the  most 
frequent  cause,  but  in  the  nulliparae  we  find  other  factors.  The  in- 
flammations of  the  mucous  lining  of  the  uterus  have  previously 


Section  of  segment  removed  for  diagnosis.  The  squamous- 
cell  carcinoma  is  replacing  the  normal  epithelimn  of 
the  cervix.  The  findings  are  typical  of  epithelioma  of  the 
cervix,  or  the  so-called  ' '  chancroid  der  portio ' '  of  the 
Germans. 


52 


THE  GYNECOLOGY  OF  OBSTETRICS 


been  considered  as  primary  and  various  classifications  of  the  sup- 
posed types  of  chronic  endometritis  and  endocervicitis,  and  are 
still  so  described.  According  to  various  investigators,  there  are  no 
changes  in  the  lining  membrane  of  the  uterus  in  the  supposed 
chronic  inflammations  which  are  not  duplicated  in  the  normal  men- 
strual cycle. 

Hitschmann  and  Adler,  in  describing  the  normal  changes  in  the 
menstrual  cycle,  divide  them  into  four  stages,  and  their  findings  are 
so  far  borne  out  by  other  observers. 

"  1.  The  premenstrual  stage,  corresponding  to  the  chronic  glan- 
dular endometritis,  begins  six  to  seven  days  before  menstruation. 

The  mucous  membrane  is 
thickened  and  develops  a 
deeper,  spongy  portion  in 
comparison  to  the  superfi- 
cial compact  layer.  There 
is  increased  glandular  ac-, 
tivity,  as  evidenced  by  the 
swelling  of  the  cells  with 
encroachment  on  the  lu- 
men, the  glands  as  a  whole 
being  more  numerous, 
large,  and  tortuous,  the 
stroma  consisting  of  large 
cells  of  the  decidual  type. 
"2.  As  the  time  of  men- 
struation approaches,  the 
vascular  engorgement  be- 
comes more  marked.  With 
the  onset  of  menstruation 
red  blood  cells  appear,  first  in  the  superficial  layers  of  the  endome- 
trium, then  in  the  cavity  of  the  uterus.  The  hemorrhage  produces  a 
rapid  detumescence  and  emptying  of  the  glands. 

"  3.  The  post-menstrual  stage,  corresponding  to  the  description 
of  chronic  interstitial  endometritis,  is  a  short  period  of  comparative 
inactivity  and  rest.  The  mucosa  appears  thin  and  pale.  The  glands 
are  straight,  oval  in  contour,  simple,  and  are  lined  with  low,  colum- 
nar eiDithelium.  The  stroma  is  composed  of  spindle  cells.  Secretion 
is  entirel}^  absent. 

"4.  The  final  stage  is  characterized  by  renewed  activity,  mitotic 
cell  diydsion  abounding.  The  glands  increase  in  size,  are  at  first 


A  portion  of  the   preceding   specimen  more  Mglily 

magnified  in   order   to   show  the  type   of  cells   and 

their  arrangement  in  finger-shaped  masses — findings 

that  are  typical  of  an  epithelioma. 


PATllOlJXiV  OK  TIIK  C'KKVIX 


53 


corkscrew  in  shape,  and  later  approach  tlie  ii  re^uhir  iMeineustrual 
tyi)e.  The  epitheliuiii  likewise  develoi)s  increasing-  activity,  wdth 
increasing-  intracellular  secretion, and  the  stroma  cells  IxM-ome  more 
succulent  and  translucent." 

Many  patients  having-  all  the  symptoms  formerly  supi)osed  to  be 
]iatlioti-nonionic  of  glan'dular  endometritis,  the  increased  bleeding 
and  leucorrhea,  have  been  shown  by  several  observers  to  have  no 


r 


Invasion  of  the  cervical  tissue  beneath  the  intact  epithelium  by 
the  cancer  cells  is  shown  in  this  section  removed  for  diagnosis. 
The  ill-defined  line  of  invasion,  the  character  of  the  invading 
cell,    and   the    line    of    round-cell    infiltration    are    characteristic. 

demonstrable  microscopical  signs  of  inflammation;  and  many 
others  without  the  supposed  classical  symptoms  do  present  what 
is  acknowledged  by  all  who  have  studied  this  problem  to  be  the  only 
true  test  of  inflammation — the  romid-cell  infiltration  from  the 
blood  plasma. 

Clinically,  it  is  evident  that  there  are  many  conditions  remote 
from  the  uterus  that   give  the   symptoms   generally  credited  to 


54 


THE  GYNECOLOGY  OF  OBSTETRICS 


endometritis  or  endocervicitis ;  this  is  emphasized  by  the  ahnost 
invariable  failure  of  a  curettage  alone  in  curing  the  patient.  Aside 
from  a  curettage  done  to  complete  the  emptying  of  the  uterus  or  to 
obtain  material  for  diagnosis,  I  feel  that  the  place  for  a  simple  cu- 
rettage does  not  exist.  From  clinical  experience,  I  feel  justified  in 
attributing  all  inflammations  of  the  cervix,  aside  from  infections, 
to  some  condition  in  the  pelvis  of  mechanical  production.  There  is 


Sec'tioii  uf  segment  removed  for  diagnosis.  The 
diagnosis  of  adenocarcinoma  of  cervix  is  made  be- 
cause of  tlie  characteristic  cells  invading  the  tissue 
beneath  the  epithelium.  There  is  no  distinct  line  of 
demarcation  between  the  cancer  cells  and  the  cervi- 
cal tissue,  but  the  surrounding  line  of  the  round- 
cell  infiltration  is  marked  and  typical. 

no  doubt  that  ovarian,  or  possibly  other  ductless-gland  pathology, 
may  stimulate  glandular  hypertrophy  or  msij  give  rise  to  the  symp- 
toms of  leucorrhea  and  hemorrhage  without  pathological  changes 
in  the  uterus,  although  severe  glandular  overgrowth  often  gives  no 
such  symptoms.  In  most  cases,  however,  these  S3anptoms  are  an 
attempt  of  nature  to  relieve  the  pelvic  congestion,  and  as  such  are 
a  benefit  to  the  patient  as  long  as  the  cause  remains,  but  it  is  abso- 


PATHOL()(JV  OF  TIIK  CP:RVIX  55 

liitely  essential  to  look  far  afield  in  order  not  to  overlook  the  causa- 
tion. 

In  this  coiineetion  a  detailed  eoiisideratioii  of  the  pathological 
possibilities  of  endometrial  changes  resulting  from  causes  away 
f  I'om  the  pelvis  is  not  in  place.  Conditions  that  produce  circulatory 
disturbances,  especially  those  increasing  blood  pressure,  are  the 
pathological  possibilities  of  greatest  importance. 

Some  men  claim  that  a  displacement  of  the  uterus  does  not  pro- 


This  section  shows  a  typically  malignant  nodule 
situated  in  the  deeper  structure  of  the  cervix.  It 
emphasizes  the  possibility  of  overlooking  a  begin- 
ning tumor  if  small  or  deeply  situated.  The  sur- 
rounding inflammatory  infiltration  is  well  shown. 

duce  congestion  of  that  organ,  and  argue  that  because  a  uterus 
does  not  change  in  color  when  replaced  it  is  not  congested.  It  does 
not  require  much  clinical  experience  to  show  that  a  uterus  rapidly 
decreases  in  size  when  replaced  or  even  held  higher  in  the  pelvis 
by  tampon  treatment.  A  knowledge  of  the  course  of  the  circulatory 
supply  of  the  uterus  with  its  tortuous  vessels  shows  how  a  very 
little  rotation  may  produce  marked  venous  stasis.  With  the  circu- 
lation interfered  with,  and  often  aggravated  by  improper  clothing 
forcing  down  the  abdominal  organs  and  interfering  with  the  ve- 


56       THE  GYNECOLOGY  OF  OBSTETRICS 

nous  flow,  it  does  not  need  any  infection  to  produce  changes  in  the 
mucous  membrane.  However,  all  the  conditions  are  present  for  the 
rapid  growth  of  germs  if  implanted. 

The  mucous  membrane,  being  the  softest  and  most  vascular  tis- 
sue, shows  the  effect  first,  and  the  more  readily  so  on  account  of  its 


The  fibrosarcoma  of  the  cervix  is  comparatively  rare.  In  this 
section  the  masses  of  embryonic  connective-tissue  cells  are  em- 
bedded in  the  fibrous  tissue  with  no  distinct  arrangement.  The 
free  blood  supply  is  fairly  well  shown,  the  vessels  exhibiting 
the  characteristic  thin  walls  of  the  sarcoma.  The  larger  vessels 
have  in  places  practically  no  walls,  and  these  are  known  as 
' '  blood  channels. "  It  is  this  construction  that  accounts  for 
the  transmission  of  these  growths  by  the  blood  stream. 

physiological  function.  As  the  uterine  cavity  does  not  readily  in- 
crease in  caliber,  the  swollen  membrane  tends  to  seek  the  course  of 
least  resistance  and  is  crowded  outward,  so  that  even  in  the  un- 
injured cervix  we  get  an  everted  mucous  membrane.  The  continued 
internal  pressure  from  the  increased  congestion  gives  in  time  a 
dilatation  of  the  canal.  In  all  these  cases  of  long  standing  the  canal 
is  abnormally  patulous.  The  mucous  membrane,  designed  to  occupy 


PATII()L()(iV  OK  MMIK  CKKXIX  .IT 

a  |)i-()t('ctt'(l  position,  wlicii  I'oi-ccd  outward  toward  the  vagina, 
wIkm-c  tlic  prcssuic  of  the  adjacent  oi-.gaiis  has  more  effect,  loses  its 
siiiule  hiyer-cell  covei-ini;'  and  an  ei-osion  results.  Within  tlie  eanal 
the  sweHin,^■  and  coiig'estion  tend  to  altei-  the  secretion  of  the 
glands,  wiiich  heconies  thicker  and  more  tenacious  in  character. 
The  gland  tlucts  become  obstructed,  and  with  the  collection  of  the 
contents  within  the  gland  itself  we  lind  i)resent  what  has  been  called 
a  cvstic  endocervicitis,  and  later,  as  some  glands  crowd  outward 


This  higher  magnification  of  the  preceding  section  of  a 
sarcoma  of  the  cervix  shows  the  embryonic  connective- 
tissue  cells  more  in  detail.  The  irregular  arrangement  of 
the  cells,  typical  of  malignancy,  also  more  clearly  shown. 

toward  the  vaginal  lining  of  the  cervix,  the  development  of  the 
cystic  cervix.  This  condition  may  have  taken  place  with  the  me- 
chanical interference  to  the  cervical  branches  of  the  nterine  arter- 
ies found  in  anteflexion  as  well  as  with  the  retrodisplacements  and 
l)r()lapse.  Such  pathology  occurs  more  rapidly  and  markedly  in  a 
case  of  lacerated  cervix  where  the  wound  has  healed  by  granulation 
process  ending  in  scar-tissue  formation.  The  contraction  of  this 
scar  tissue  seriously  interferes  with  the  blood  and  nerve  supply. 
The  old-time  ''ulcerated  cervix"  of  the  woman  who  has  had 


58       THE  GYNECOLOGY  OF  OBSTETRICS 

children  is,  as  was  first  emphasized  by  Emmet,  the  end  result  of 
the  ' '  ectropion, ' '  or  turning  outward  of  the  normal  mucous  mem- 
brane of  the  canal.  The  read- 
ily bleeding  area  around  the 
OS,  which  is  looked  upon  as 
an  ulceration,  is  the  mucous 
membrane  of  the  cervical  ca- 
nal eroded  through  exposure 


A  chorioepitheliiiiiiH  of  the  cervix.  In 
this  ease  the  growth  is  situated  be- 
neath the  intact  epithelial  covering.  The 
irregular  arrangement  of  the  embryonic 
structures  surrounding  and  penetrat- 
ing the  blood  sinuses  is  typical  of  this 
type  of  malignancy.  A  chorioepitheli- 
oma  must  of  necessity  be  associated 
with  a  pregnancy  of  some  type  or  a 
teratoma,  on  account  of  the  villi  base. 
Pick  has  demonstrated  the  occurrence 
of  practically  all  the  body  elements  in 
teratomata,  or  so-called  ' '  dermoids, ' ' 
except  the  villi,  but  the  occurrence  of 
chorioepithelioma  in  non-pregnant  wom- 
en, and  occasionally  in  men  where 
' '  dermoids  ' '  existed,  would  seem  to 
pro\e  the  presence  of  villi  in  such  cases. 


A  section  from  a  case  of  metastatic  chorio- 
epithelioma with  the  primary  growth  in 
the  cervix.  At  abdominal  section  a  diagno- 
sis of  tuberculous  peritonitis  was  made 
from  the  gross  appearance  of  the  lesions. 
The  tumor  presents  the  characteristic  ap- 
pearance of  this  growth  as  well  as  some 
fatty  tissue  of  the  omentum  from  which 
the  nodule  was  taken.  The  section  is  from 
the    laboratory    of    Prof.    Ludwig    Pick. 


A  higher  magnification  of  the  metastatic  cho- 
rioepithelioma on  the  omentum.  It  shows  the 
typical  elements  of  the  growth  and  their  re- 
lation to  the  blood  cavities. 


rATIIOIJXiV  OF  TIIK  CKKN'IX  59 

to  friction,  and  rnrtiicr  congested  and  swollen  by  nature's  efforts 
to  Ileal  by  lynipli  infiltration.  Tliis  healing-  process  imposed  upon 
the  incchanical  congestion  I'aN'ors  tlic  overgrowth  of  tlie  deeper 
structures  and  a  hypertrophy  of  the  ventral  and  dorsal  lips  re- 
suits,  wliicli  tends  to  further  exi)ose  the  canal  lining.  It  has  al- 
ready lieeii  shown  how  the  relaxed  vaginal  outlet,  by  its  mechanical 


^. 


Chorioepithelioma  of  the  cervix.  The  characteristic  findings  in  this  type  of 
growth  are  the  presence  of  villi  elements,  irregular  overgrowth  associated 
with  large  blood  spaces.  Pick  says,  * '  Villi  hunt  blood  as  a  magnet  hunts 
steel,"  and  so,  naturally,  in  the  malignant  development  of  tliese  embry- 
onic elements  the  same  close  association  with  blood  cavities  is  present. 
Tn  this  specimen  the  villi  are  still  intact,  and  there  is  marked  irregular 
]iroliferation  of  the  syncytial  cells  Avith  invasion  of  the  stroma. 

effect,  can  produce  the  same  general  condition.  Outside  of  these 
pathologies  of  the  cervix,  we  can  discard  all  the  old-time  varieties 
of  cervical  inflammations  designated  mider  the  head  of  endocer- 
vicitis,  for  the  round-cell  infiltration  alone  can  be  considered  diag- 
nostic of  chronic  inflammation,  and  the  presence  of  pus  and  germs 
of  the  acute. 

Tn  considering  the  question  of  cervical  erosion  I  am  limiting  the 
discussion  to  those  cases  Avhich  are  the  result  of  passive  congestion 


60 


THE  GYNECOLOGY  OF  OBSTETRICS 


or  injury.  These  are  the  two  types  which  naturally  fall  into  the 
limits  of  this  monograph. 

I  do  not  wish  to  be  understood  as  including  in  this  question  of 
etiology  the  type  of  erosion  and  eversion  found  in  infants,  the  con- 
genital form ;  or  that  found  in  pregnant  women,  which  is  probably 
the  result  of  overgroAvth  of  glandular  structure ;  or  the  type  asso- 


This  higher  niagnification  of  the  preceding  section  shows  in  detail  the 
large,  deeply  staining  Langhan  's  cells  with  their  well-defined  membrane 
and  the  smaller  syncytial  cells  with  indistinct  cell  membrane.  These  two 
elements  are  typical  of  the  villi  structure,  but  normally  occur  associated 
in  single  layers.  In  the  malignant  overgrowth  these  elements  form  in 
masses  with  no  regular  arrangement.  Here  the  blood  spaces  are  well 
shown,  but  with  no  blood  elements  present. 

ciated  with  the  presence  of  the  gonococcus,  diphtheroid  bacillus,  or 
other  germs  which  cause  irritating  discharges.  Eliminating  these 
forms  naturally  takes  out  of  the  discussion  the  various  theories  ad- 
vanced by  Huge,  Veit,  Fischel,  Gottschalk,  and  others,  which  deal 
with  the*  glandular  perforation  from  below  the  epithelium,  the  sub- 
epithelial hemorrhage  in  inflammations,  and  the  other  processes 
which  can  produce  erosions  in  loco. 

The  erosion  under  consideration  is  essentially  an  inflammatory 


l\\TII()IJ)(iV  OK  TIIK  CKin'IX  61 

])i-()('("ss  nssociatcMl  with  roiiiKl-ccll  iiililti-atioii  and  scai--tissu('  for- 
mation. That  the  i-oiiii(l-<'('ll  iiililtratioii  pi'cccdcs  the  ci'osioii  in 
isonic  case  is  appai-cnt,  more  cspcciallN-  so  in  i-ccui-rciiccs. 

The  most  connnon   picture  in  the  pi-occss  of  hcalin.i--  is  the  raw 


A  section  of  an  eroded  cervix.  The  stratified  sqnamous  epithelium 
'  has  disappeared  from  a  considerable  area.  The  mucous  membrane 
lining  the  cavity  is  also  wanting.  The  eroded  surface  is  covered 
by  a  blood-clot.  Some  of  the  glands  are  slightly  cystic,  and  the 
tissue  near  the  eroded  area  shows  marked   round-cell   infiltration. 

area  covered  by  granulatioii  tissue  and  that  by  pavement  epitlieli- 
iim,  to  be  replaced  again  later  by  the  stratified  squamons  form.  It 
is  probable  that  in  some  cases  the  epithelial  covering-  comes  from 
the  colmnnar  cells  of  the  cervix  or  from  islands  of  epithelium  in 
the  raw  area.  In  time  this  squamous  epithelium  is  replaced  by  the 
more  resistant,  slower-growing  stratified  cells. 


62 


THE  GYNECOLOGY  OF  OBSTETRICS 


It  is  the  round-cell  infiltration,  with  its  scar-tissue  formation, 
interfering  with  the  circulation  and  the  gland  secretion,  that  causes 
a  recurrence  and  demands  operative  treatment  for  permanent  cor- 
rection. 

In  the  chapter  on  the  etiology  of  pelvic  injuries  the  effect  of  the 
tight  binder  has  been  spoken  of  as  a  possible  factor  in  preventing 
primary  union  of  an  injured  cervix,  and  thus  giving  rise  to  the 
chronic  pathological  conditions  just  discussed.  If,  at  the  same  time, 


A  section  from  an  eroded  cystic  cervix.  The  glands  are  increased 
in  size  and  number.  One  has  become  definitely  cystic.  The  stratified 
squamous  epithelium  has  been  destroyed,  and  near  the  raw  surface 
the  inflammation,  as  evidenced  by  the  plasma-cell  infiltration,  is 
marked.  In  this  section  there  is  some  evidence  of  a  beginning  heal- 
ing process. 

on  this  granulating  area  any  degree  of  infection  is  imposed,  the 
greater  degree  of  infiltration  and  the  slower  healing  exaggerate 
the  mechanical  defect. 

It  will  not  be  amiss  here,  while  considering  cervical  pathology, 
to  mention  a  factor  which  is  not  always  recognized  as  of  injury  to 
the  cervix,  and  that  is  the  pessary.  The  pessary  holds  the  uterus 
forward  by  a  stretching  of  the  upper  portion  of  the  vaginal  canal, 
especially  the  dorsal  fornix,  also  by  a  relative  shortening  of  the 
sacrouterine  ligaments  through  giving  them  a  new  point  of  attach- 


PATHOLOGY  OF  THE  CERMX 


63 


meiit  at  the  pessary's  transverse  bar.  Both  these  actions,  while 
maintainino-  the  position  of  the  litems,  i)nt  tension  on  the  dorsal 
attachments  of  tlie  cervix,  thns  tending-  to  separate  the  lips  and  ex- 
aggerate any  defect.  If  a  cystocele  is  present,  it  is  partially  relieved 
l)y  the  liolding-  u\)  of  the  vaginal  vanlt  and  cei'vix  and  the  stretch- 
ing of  the  vagina  laterally,  ))nt  this  gives  no  direct  snpport  to  the 
body  of  the  cystocele.  Thns  the  weight  of  the  nrine  is  exerted  be- 
tween the  bars  of  the  pessary  npon  the  rectum,  and  this  is  rather 


A  more  highly  niii^iiifiiMl  section  of  a  nuirkcd  i-asc  nf 
erosion.  The  gland  epithelial  covering  is  intact  as  far 
as  the  eroded  surface.  The  extreme  round-cell  infil- 
tration, with  the  ragged  raw  surface  from  which  the 
epithelial  covering  has  disappeared,  indicates  the 
acuteness  of  the  pathology. 

exaggerated, if  anything, by  the  position  of  the  fnndns  above.  Natu- 
rally, the  greater  portion  of  this  strain  comes  then  upon  the  cervix, 
especially  the  ventral  lip,  and  thus  the  pathology  is  rapidly  exag- 
gerated. In  fact,  so  great  is  this  pull  on  the  cervix  that  in  cases 
where  a  pessary  has  been  necessary  after  a  trachelorrhaphy,  it  has 
often  been  found  that  the  new-formed  line  of  union  has  stretched 
out  markedly,  and  a  recurrence  of  the  ectropion  has  occurred, 
necessitating  a  second  repair  when  the  abdominal  work  is  done. 
In  cases  in  which  a  relaxed  vaginal  outlet  was  not  repaired  at 


64 


THE  GYNECOLOGY  OF  OBSTETRICS 


the  same  time  as  the  cervix  (which  is'  by  no  means  uncommon, 
through  lack  of  recognition  or  lack  of  appreciation  of  the  signifi- 
cance of  a  poor  diaphragm  support),  the  effect  on  the  cervix  is  one 
of  hypertrophy  and  elongation  as  a  result  of  the  pull  from  below, 
instead  of  the  separation  of  the  cervical  lips.  In  time,  with  the  fall- 
ing of  the  uterus,  the  ectropion  will  occur. 


Section  from  a  cystic  cervix  that  shows  the  loss 
of  the  stratified  epitlielial  covering  and  the  char- 
acter of  the  cystic  development  of  the  glands. 
The  cervical  structure  beneath  the  raw  area 
shows  intense  round-cell  infiltration.  The  cells 
lining  the  cyst  cavities  are  uniform  in  struc- 
ture, with  an  intact  basement  membrane.  The 
cavities  contain  some  round  cells  in  the  remains 
of  the  mucous  secretion. 


PATllOLOdV  OK  ^rilE  CKRVIX 


r 


1 


65 


Au  eroded  cervix  that  is  beginning  to  heal.  The  infiltration  is 
marked,  but  the  glandular  elements  are  not  nearly  so  prominent  in 
this  case.  The  healing  is  taking  place  by  the  covering  of  the  raw 
area  with  a  single  layer  of  squamous  cells.  These  are  replaced  later 
by  the  stratified  epithelium. 


A  more  higlily  magnifie<l  jiortioii  of  the  preceding  section  that 
shows  more  in  detail  the  process  of  repair.  A  fairly  definite  cover- 
ing of  a  single-cell  flattened  epithelial  layer  has  formed  over  the 
raw  area.  This  layer  probably  has  its  origin  from  three  possible 
sources:  islands  of  epithelium  that  remained  from  the  original 
covering;  the  epithelium  lining  the  gland  ducts;  or  the  edges  of 
the  intact  mucous  membrane.  This  single  layer  of  cells  is  gradually 
replaced  by  the  stratified  epithelium  of  the  cervix.  The  round  cells 
beneath  form  more  or  less  scar  tissue,  which  is  one  of  the  reasons 
for  a  recurrence  of  the  condition. 


SYMPTOMS  OF  CERVICAL  PATHOLOGY 

IT  IS  not  possible  to  differentiate  any  symptoms  or  an}^  set  of 
symptoms  as  typical  of  cervical  injury  or  inflammation.  The 
symptoms  that  we  get  with  these  two  classes  of  pelvic  pathol- 
ogy are,  as  with  many  other  pelvic  abnormalities,  the  result  of 
the  associated  or  resultant  congestion. 

The  leucorrhea,  probably  the  most  noticeable  and  often  the  earli- 
est sign,  is  nothing  more  than  the  increased  secretion  of  the  uter- 
ine and  cervical  glands,  the  function  of  which  is  stimulated  by  the 
greater  blood  supply.  If  this  discharge  is  of  a  thick,  tenacious  char- 
acter, it  probably  has  its  origin  from  the  glands  within  the  cervical 
canal,  for  the  uterine  gland  secretion  is  of  a  more  watery  nature. 
This  cervical  discharge  is  so  tenacious  in  some  cases  that  it  is  al- 
most impossible  to  wipe  it  away  without  the  aid  of  some  chemical 
reagent  to  coagulate  or  dissolve  it. 

The  normal  reaction  of  the  uterine  secretion  is  alkaline,  but  in 
many  of  these  inflammatory  processes  it  is  acid,  on  account  of  a 
superimposed  bacterial  growth.  The  tenacious  character  of  the  dis- 
charge and  the  change  from  the  normal  reaction  are  often  the 
factors  that  prevent  pregnancy.  Outside  of  the  appearance  of  the 
cervix,  they  are  the  only  signs  that  might  be  considered  typical  of 
cervical  pathology. 

With  many  cervical  abnormalities,  we  find  increased  or  irregular 
menstruation,  and  this  is  especially  so  with  the  cystic  cervix.  Such 
symptoms  indicate  simpl}^  an  increased  blood  suppl}^  The  mechan- 
ical irritation  of  nerve  endings  through  involvement  in  the  scar 
tissue  may  possibly  have  considerable  reflex  eifect  in  producing 
this  congestion.  Associated  with  the  uterine  hyperemia,  there  is 
always  a  more  or  less  marked  congestion  of  the  ovaries,  and  prob- 
ably this  ovarian  irritation  also  stimulates  the  uterine  flow. 

In  women  nearing  the  menopause  we  have  other  causes  for  men- 
orrhagia  or  metrorrhagia,  such  as  a  sclerotic  degeneration  of  the 
uterine  blood-vessels  or  a  polypoid  growth  of  the  mucous  mem- 


SVMI'I^OMS  OK  (M^]in'l(\\L   I'A^niOLOGY  67 

bfauc.  '^riicsc  arc  ('oiiditioiis  tlint  do  not  |)r('S('iil  ('1ioii,l;1i  ,i;ross  pa- 
tliolo^'V  to  he  i-cadilx  iccooiiizcd,  and  an  associate*!  cciA'ical  pathol- 
ogy may  be  ,i;'i\('n  crc(lit  foi-  the  inci-eased  flow.  Tlicrc  are  ai;-ain 
general  sxstcinic  conditions  causing  increased  hlciMling,  wliicli  may 
also  he  ox'ei  looke<h 

A  very  t're(iueiit  syiiiptoni  associated  with  the  al)n()rnial  cervix  is 
the  irritated  bladder.  The  ch)se  relation  of  tlie  cervix  to  the  blad- 
der anatomically,  with  the  common  sonrce  of  ))lo()d  sni)i)ly,  will 
always  produce  an  associated  congestion  in  tlie  bladder,  especially 
at  its  base.  It  is  this  congestion  that  accounts  for  the  bhiddei-  syjnp- 
toms.  In  these  cases  the  cystoscope 
shows  a  congested  trigone  or  the  pap- 
illary enlargement  at  the  internal 
sphincter,  the  latter  being  especially 
characteristic  of  pelvic  congestion. 
The  urine  show^s  no  change  unless  the 
enlarged  cervix  by  gravitation  drags 
down  the  bladder,  producing  a  degree 
of  urine  stasis.  In  such  cases  there  is 
associated  a  mild  grade  of  urosepsis, 
indicated  by  a  bacteriuria.  The  symp- 
toms complained  of  are  the  frequent 
and  sometimes  painful  micturition 
with  a  feeling  of  incomplete  evacua- 
tion. 

A  woman  complaining  of  these 
symi)toms  should  not  be  allowed  to  go  Avithout  a  thorough  examina- 
tion. In  nulliparae  the  symptoms  may  onh^  be  an  indication  of  a 
pathological  anteflexed  uterus ;  but  wdtli  that  is  usually  associated 
the  painful  menstruation  characterized  by  pain  appearing  some 
hours  before  the  flow  and  usually  relieved  thereby.  However,  in 
later  life,  with  the  further  pathological  changes,  which  result  in  an 
enlargement  and  softening  of  the  uterus,  the  pain  may  disapjDear. 
A  pain  continuing  after  the  flow^  is  w^ell  established  is  usually  in- 
dicative of  complicating  tubal  or  ovarian  pathology. 

It  is  necessary  to  bear  in  mind  that,  on  account  of  its  histological 
structure,  the  cervix  is  not  capable  of  giving  rise  to  any  very 


Erosion  of  the  miinjiired  virgin  cer- 
vix. The  (lark  area  aronnd  the  os  is 
the  eroded  portion. 


68       THE  GYNECOLOGY  OF  OBSTETRICS 

marked  symptoms  directly,  and  consequently  only  indirectly  does 
it  indicate  its  condition.  AVlien  that  indication  is  prominent,  the  de- 
gree of  pathology  is  usually  marked.  This,  however,  does  not  apply 
to  the  reflex  nervous  symptoms,  which  will  be  considered  more  in 
detail  in  the  discussion  of  the  relaxed  vaginal  outlet,  since  the  two 
are  frequently  associated  and  the  reflex  symptoms  of  both  are  simi- 
lar; yet  any  of  the  reflex  symptoms  found  with  pelvic  congestion 
may  occur  with  the  cervix  alone  as  the  etiological  factor,  while  the 
local  signs  may  not  have  particularly  attracted  the  woman's  at- 
tention. 

In  conclusion,  it  is  necessary  for  us  to  remember  that  the  pa- 
thology of  the  cervix  has  no  definite  symptomatology,  and  that  the 
leucorrhea,  menorrhagia,  metrorrhagia,  with  bladder  irritation, 
backache,  and  reflex  nervous  symptoms,  so  frequently  given  as  in- 
dicative of  cervical  abnormalities,  are  purely  the  result  of  the  asso- 
ciated congestion.  The  presence  of  one  or  more  of  these  symptoms 
should  lead  to  a  thorough  investigation  of  the  pelvis  as  a  whole, 
with  the  realization  that  the  cervical  condition  alone  is  sufficient  to 
account  for  all  these  symptoms,  though  there  is  always  a  likelihood 
of  an  associated  pathology. 


TREATMENT  OF  CERVICAL  PATHOLOGY 

TIIK  troatiiioiit'of  tlic  patliolooioal  foiiditioiis  of  the  cervix  is 
essentially  surgical.  Apart  from  the  acute  venereal  involve- 
ments, it  has  been  shown  that  in  the  majority  of  cases  the 
abnormalities  of  the  cervix  have  a  mechanical  origin.  It  is 
necessary,  therefore,  in  order  that  permanent  results  be  obtained, 
to  correct  the  mechanical  defect,  and  this  naturally  involves  surgi- 
cal ])rocedures. 

Without  doul)t,  local  applications  to  the  uterus  with  the  custom- 
ary depleting  methods  have  a  place  of  great  value.  In  most  cases, 
however,  this  treatment  is  mainly  of  advantage  as  a  preparation 
for  operation  or  a  post-operative  procedure  to  correct  a  lingering- 
inflammation. 

In  cases  of  marked  cervical  congestion  associated  with  lacera- 
tion, Emmet  recognized  the  fact  that  the  discharge  persisted  for 
some  months  after  the  operation,  and  he,  with  others,  advised  and 
practiced  treatments  for  long  periods  preceding  the  operation, with 
the  hope  that  this  would  clear  up  the  discharge  more  rapidly.  AVe 
realize  now  that  such  preparatory  treatment  is  of  value  in  cases  of 
marked  hypertrophy  or  cystic  formation,  especially  if  combined 
with  scarification  and  the  puncture  of  the  cysts.  But  it  is  not  neces- 
sary to  extend  the  treatments  beyond  the  point  of  the  first  improve- 
ment, for  the  operation  will  promptly  take  care  of  the  balance  of 
the  congestion.  It  is  not  uncommon  in  some  cases  to  find  a  persis- 
tence of  the  leucorrhea  for  a  few  months  after  an  operation,  but  if 
the  work  has  been  correctly  done  this  in  many  cases  finally  disap- 
pears, even  without  treatment.  A  certain  amount  of  discharge  is 
probably  the  result  of  the  presence  of  the  absorbable  sutures  with- 
in the  tissue;  for,  no  matter  how  little  previous  inflanmiation  or 
how  slight  the  operation,  when  absorbable  sutures  are  employed,  a 
discharge  appears  after  a  few  days  and  persists  until  the  catgut 
disappears. 

It  is  true  that  by  treatment  we  can  clear  up  severe  cases  of 


70       THE  GYNECOLOGY  OF  OBSTETRICS 

ectropion,  but  naturally  such  cases  do  not  stay  cured,  since  the 
causative  factor  remains.  There  is  still  another  reason,  aside  from 
the  primary  etiology,  for  the  period  of  only  temporary  improve- 
ment, and  that  is  the  round-cell  infiltration  concurrent  with  the 
mucous-meiubrane  irritation  and  erosion.  This  plasma-cell  process 
results  in  more  or  less  scar-tissue  formation,  even  below  the  re- 
formed mucous  membrane,  which  naturally  interferes  with  the 
gland  ducts,  tending  to  the  production  of  cystic  glands.  It  is  nat- 
ural, then,  to  find  a  patient  with  such  pathology  returning  in  a  few 
months  with  a  similar  if  not  a  more  severe  condition. 

In  the  acute  venereal  inflammations  of  the  cervix,  prompt  im- 
provement is  usually  obtained  from  the  application  of  silver  ni- 
trate solution  to  the  surfaces  involved,  and  such  application  is  of 
especial  value  where  raw  surfaces  exist.  Ten-  to  twent^^-per-cent 
solutions  are  usually  of  most  value.  Argyrol  in  twenty-per-cent, 
protargol  in  five-per-cent  solution,  or  some  of  the  other  numerous 
organic  silver  salts,  are  much  used,  but  in  this  particular  location, 
as  well  as  in  the  vagina,  they  are  by  no  means  as  satisfactory  as 
the  silver  nitrate.  Experimental  work  reported  by  Noble  upon  the 
germicidal  value  of  silver  nitrate,  as  compared  with  protargol  and 
argyrol,  has  shown  that  the  latter  drugs,  which  come  in  the  class  of 
organic  compounds,  have  little  value  as  gonococcides.  In  gonor- 
rhea the  silver-nitrate  applications,  followed  b}^  yeast  or  Cervisine 
tampons,  usually  yield  prompt  results,  unless  the  process  has  ex- 
tended above  the  internal  os  so  that  there  is  reinfection  through 
the  discharge  from  above. 

A  primary  or  a  secondary  syphilis  seldom  calls  for  treatment, 
for  in  the  majority  of  cases  the  condition  is  overlooked,  and  natu- 
rally^ in  time  responds  to  the  systemic  medication.  In  case  the  le- 
sions are  discovered,  they  may  be  treated  as  is  similar  pathology 
in  other  parts  of  the  body. 

In  chronic  conditions  of  the  cervix,  the  usual  routine  treatment 
has  as  its  basis  applications  of  some  antiseptic  or  caustic  applied 
to  the  cervix  and  its  canal,  followed  by  depleting  drugs  placed 
upon  tampons  or  used  in  the  shape  of  suppositories.  The  once  com- 
monly advocated  treatment  of  applying  drugs  to  the  cavity  of  the 
uterus  itself  has  fortunately  fallen  into  disuse.  There  is  danger  of 


TREATMF.XT  OF  CKKVK'AF  l\\TII()I/)(i V  71 

))i-()(]ii('iii,iA'  sudden  i^i^vrvv  collapse  followed  l)y  pei-iloiieni  ii-fitation 
tlirouii,ii  direct  passage  of  the  dvwj;  to  the  peritoiiemii,  even  if  used 
ill  mild  solutions.  Obliteration  of  the  cavities  of  the  uterus  or  tubes, 
if  stronger  caustics  are  use(l,  is  not  at  all  impossible.  In  fact,  liter- 
ature lias  numerous  examples  of  such  misadNcntui'cs.  On  the  other 
hand,  it  is  very  (luestibnable  whether  such  applications  accomplish 
any  good  purpose.  Lately  a  suggestion  has  been  made  of  injecting 
just  before  abdominal  section  a  tw^enty-five-per-cent  solution  of 
tincture  of  iodine,  in  order  to  determine  the  patulousness  of  the 
tubes.  In  some  rare  cases  this  may  possibly  be  of  advantage,  but 
we  must  bear  in  mind  the  marked  irritation  that  iodine  exerts 
upon  the  peritoneal  surfaces,  and  that  the  result  may  be  a  second- 
ary closure  of  the  unobstructed  tubes. 

The  most  widely  used  application  to  the  cervix  is  probably 
Churchill's  tincture  of  iodine.  It  is  antiseptic,  somewdiat  caustic, 
and  by  its  ready  absorption  penetrates  more  readily  into  the  tis- 
sues. Iodine  thus  applied,  it  has  been  demonstrated,  can  be  recov- 
ered from  the  urine  wdthin  fifteen  minutes.  This  show^s  how  rapidly 
some  drugs  can  be  thus  absorbed,  and  should  w^arn  us  against  the 
use  of  too  poisonous  applications. 

Ichthyol,  ichthyol  wdtli  guaiacol,  the  organic  silver  salts,  carbolic 
acid  follow^ed  by  alcohol,  picric  acid,  tannic  compounds  or  tan- 
nic acid  in  tincture  of  iodine  are  favorite  applications  of  some 
gynecologists,  though  it  is  questionable  if  just  as  much,  if  not  more, 
good  is  done  by  the  use  of  the  iodine  tincture,  unless  the  patient 
has  an  idiosyncrasy  to  iodine.  Silver  nitrate  and  picric  acid,  on  ac- 
count of  their  coagulating  action,  have  a  narrow^er  field  of  useful- 
ness, but  properly  used,  in  their  individual  sphere,  are  of  greater 
value  than  any  of  the  other  drugs  mentioned.  In  some  chronic  in- 
fections basic  fuchsin  in  saturated  acpieous  solution  is  very  service- 
able. 

Practically,  all  tampon  medicants  contain  glycerin  or  boroglycer- 
ide,  or  both,  for  such  drugs  applied  to  the  cervix  produce  a  serous 
exudate  that  depletes  the  circulation,  thus  helping  to  relieve  the 
congestion.  In  case  a  tampon  of  elastic  material  is  used,  this  pro- 
cess is  further  aided  by  the  elevation  of  the  uterus  and  the  result- 
ing improved  circulation.  It  is  mainly  in  this  particular  that  the 


72       THE  GYNECOLOGY  OF  OBSTETRICS 

largely  sold  proprietary  tampons  fail;  the  drug  ingredients  used 
are  of  value  through  the  antiseptic  and  depleting  properties,  but 
no  self-applied  tampon  or  no  enclosed  tampon,  even  if  inserted  by 
the  medical  attendant,  can  ever  be  properly  placed  to  obtain  the 
greatest  benefit.  Consequently,  the  cheaper  vaginal  suppositories 
accomplish  just  as  much  when  home  methods  of  treatment  seem 
warranted. 

While  glycerin  is  an  excellent  depletive  for  ordinary  use,  if  very 
active  depletion  is  desired,  a  powdered  C.P.  magnesium  sulphate 
is  of  value,  applied  as  a  dr}^  powder  upon  the  tampon  or  made  up 
as  a  vaginal  suppository. 

The  tampon  itself  is  most  serviceable  when  made  from  carded 
Australian  lamb's  avooI.  This  may  be  obtained  in  rope  form,  so  that 
the  required  length  is  easily  cut  off,  and  with  a  soft  string  of  Dex- 
ter's  cotton  attached  to  the  middle  its  Avithdrawal  is  made  easy  for 
the  patient.  The  carded  wool  is  non-irritating  and  is  sufficiently  ab- 
sorbent, so  that  there  is  no  necessity  of  having  a  covering  of  cotton. 
It  is  also  remarkably  elastic,  does  not  become  packed,  like  cotton, 
and,  consequently,  holds  the  structures  upward  with  no  injurious 
effect.  A  little  advice  to  the  patient  regarding  its  removal  is  wise, 
for  if  it  is  withdrawn  too  suddenly  the  suction  action  will  often  in 
acute  conditions  cause  pain,  as  well  as  tend  to  reproduce  a  re- 
placed retroverted  uterus.  When  cotton  is  used  for  tampons,  it 
becomes  so  packed  when  moist  that  upon  withdrawal  it  will  act  as 
a  piston,  tending  to  drag  down  the  structures  above.  These  local 
treatments  should  be  augmented  by  the  long  hot  vaginal  douche, 
directed  to  be  taken  at  home  upon  the  removal  of  the  tampon.  No 
tampon  should  be  permitted  to  stay  longer  than  twenty-four  hours 
within  the  vagina,  on  account  of  the  ready  decomposition  of  re- 
tained secretions. 

The  value  to  be  derived  from  a  hot  douche  comes  only  from  an 
application  of  the  heat  sufficientl^T^  long  to  accomplish  the  contrac- 
tion of  the  vessels.  Any  douche  of  short  duration  had  better  be  used 
at  body  temperature,  in  order  to  avoid  a  dilatation  of  the  vessels 
with  the  resulting  increased  blood  suppl}^,  which  is  always  the  first 
action  of  hot  applications.  To  obtain  the  contraction  of  the  capilla- 
ries, the  douche  must  be  of  a  temperature  of  at  least  110°  F.  and  of 


TREATMENT  OF  CEKVTCAT.  PATITOLOGY  73 

contiimoiis  ap})lieation  for  at  least  ten  minutes,  oi-  ))ettei-  twenty. 
To  ()l)tain  tlio  best  i-esults,  tlie  woman  must  be  on  her  back,  for  this 
allows  the  thorough  bathin<;-  of  the  cervix  and  vaginal  vault  in  the 
liot  (hiid.  No  great  pressure  is  advisable,  and  the  container  should 
be  so  iiung  as  to  give  a  slow  sti'eam,aiid  more  liot  water  added  from 
time  to  time  to  maintain  the  temi)erature.  To  the  water  may  be  add- 
ed sufficient  salt  for  a  physiological  salt  solution,  or  the  same  pro- 
])ortion  of  sodium  bicarbonate.  These  ingredients  help  to  liquefy 
the  secretions,  thus  washing  them  away  more  easily,  and  if  the  dis- 
charge is  excessively  acid  the  soda  will  neutralize  it  somewhat. 
There  is  no  objection  to,  and  there  may  be  great  value  in,  combining 
l)()tii  drugs.  An  antiseptic  such  as  lysol,  which  by  its  soapy  charac- 
ter and  alkaline  reaction  dissolves  and  neutralizes  the  secretions, 
may  be  used,  though  little  can  be  expected  from  the  antiseptic  it- 
self, and  much  more  can  be  accomplished  in  that  way  by  direct 
application  of  iodine  or  argyrol  to  the  cervix  and  vagina.  If  w^e 
desire  an  astringent  action,  a  drachm  each  of  zinc  sulphate  and 
alum  for  each  quart  of  water  may  be  added  to  the  last  of  the  water 
used,  thus  avoiding  the  use  of  an  excessive  quantity  of  the  prescrip- 
tion. If  the  discharge  is  odorous,  a  solution  of  permanganate  of 
potash  is  useful ;  but  under  no  conditions,  except  syphilis  perhaps, 
is  the  use  of  bichloride  of  mercury  or  other  mercurial  salts  indi- 
cated. In  most  women,  used  even  in  moderate  quantity,  these  are 
irritants,  coagulating  instead  of  removing  the  secretions,  and  are 
capable  of  producing  toxic  symptoms  through  absorption. 

It  is  w^ell  to  bear  in  mind  that  some  w^omen  are  able  to  stand  ex- 
cessively hot  douches,  and  the  use  of  such  are  followed  by  consider- 
able relaxation  of  the  tissues  rather  than  the  toning  up  desired. 
Consequently,  it  is  well  to  order  a  bath  thermometer  and  advise  the 
temperature  to  be  kept  between  110°  and  115°. 

A  few  w^eeks  of  treatment  of  this  character  will  usually  accom- 
plish all  the  improvement  that  we  can  hope  to  gain  in  this  w^ay.  So, 
if  the  pathology  persists,  any  doubt  of  the  necessity  for  more  radi- 
cal treatment  is  removed. 


IMMEDIATE  REPAIRS 

THE  ideal  treatment  of  the  injured  cervix  would  naturally 
be  the  repair  at  the  time  of  labor.  Such  a  procedure,  how- 
ever, is  in  most  cases  too  difficult  to  be  readily  accomplished 
under  the  conditions  surrounding  confinement  work  outside 
of  a  hospital.  The  factors  determining  most  writers'  recommenda- 
tion to  leave  the  injured  cervix  alone  have  already  been  discussed. 

In  all  cases  of  severe  laceration  of  the  cervix,  with  or  without 
bleeding,  a  careful  repair  does  not  add  to  the  risk  of  infection  if 
the  asepsis  is  good.  In  fact,  closing  in  the  raw  areas  will  lessen  the 
risk  of  autoinfection.  If  severe  bleeding  occurs,  it  is,  of  course, 
necessary  to  control  it  b}^  suture,  no  matter  what  the  environments. 
GrasiDing  the  cervical  lips  with  two  double  vulsellum  forceps, 
through  a  Graves  operating  speculum  it  is  possible  to  readily  lo- 
cate the  torn  edges  and  by  traction  downward  facilitate  the  intro- 
duction of  the  sutures.  Sutures  of  silkworm  gut  or  silver  Avire, 
which  do  not  stretch  or  swell  and  leave  no  foreign  culture  medium 
in  the  tissues,  are  best  suited  to  this  particular  need.  These  should 
be  tied  tight  enough  to  hold  the  parts  in  approximation  even  after 
the  uterus  has  undergone  its  preliminar}^  rapid  involution,  though 
care  must  be  taken  to  avoid  tension  of  a  degree  that  will  strangu- 
late the  tissues.  The  results  in  man}'  cases  will  be  as  perfect  as  a 
later  Emmet  operation. 

The  immediate  repair  of  the  injured  outlet  is  a  problem  to  be 
considered  independently^  of  the  relaxed  vaginal  outlet,  for  here  we 
do  no  denudation,  and  the  question  involved  is  one  of  correct  ap- 
proximation. It  would  seem  as  if  this  approximation  of  the  raw 
surfaces  in  their  original  location  was  a  simple  matter,  but  there 
are  always  factors  involved  that  tend  to  render  the  work  difficult. 

As  a  rule,  the  patient  is  cared  for  under  conditions  which  do  not 
favor  careful  examinations  or  easy  manipulations.  The  patient 
having  accomplished  the  birth  of  the  child,  is  impatient  of  any  fur- 
ther inconvenience.  The  giving  of  more  anesthetic  is  not  alwavs 


lALMKDIATK   RKPAIKS  75 

(l('siral)l('.  The  (idd  is  ohsciiriMl  hy  hlood,  and  added  to  this  tlio  in- 
€onveiiieiK'C'  of  liaviiii;-  to  do  the  work  upon  a  bed,  in  place  of  tiie 
almost  essential  tal)Ie,  makes  tlioi-oui;h  examination  of  the  injury 
almost  impossible.  These  factors  combined  with  the  lack  of  assis- 
tants to  aid  the  alrea<ly  ti  red-out  nurse  an<l  attendant  pi'event  care- 
ful and  sometimes  necessarily  elaboi-ate  repair. 

However,  tlie  time  chosen  for  the  repair  is  important.  Thei"e  is 
no  doubt  that  tlie  l)est  results  are  ohtained  when  the  work  is  done 
immediately  after  the  completion  of  lal)oi'.  Some  autliorities  advise 
the  placinii,-  of  the  sutures  while  waiting-  for  the  birtli  of  the  pla- 
centa. If  this  is  done,  and  the  repair  is  made  with  interrupted 
sutures,  it  is  important  that  they  should  be  left  untied  until  after 
the  delivery  of  the  placenta,  or  the  necessity  for  further  uterine 
manipulations  is  ended. 

The  Berkeley  and  Bonney  Gynecology  says:  "The  perineum 
should  never  he  repaired  until  it  is  certain  the  uterus  has  satisfac- 
torily contracted,  for  if  digital  exploration  is  required,  the  sutures 
will  he  torn  out." 

If  the  sutures  are  torn  out,  the  fact  wdll,  naturally,  he  recognized, 
and  they  will  he  replaced.  The  possibility"  is  that,  instead  of  tear- 
ing out  completel}',  the  sutures  have  cut  through  only  a  portion  of 
the  tissue,  and  this  will  pass  unnoticed.  The  tissues  at  this  time 
heing  soft  and  friable  and  the  sutures  more  resistant,  a  certain 
amount  of  cutting  by  the  latter  readily  takes  place  when  any  strain 
is  applied.  This  naturally  interferes  with  healing  through  the  im- 
perfect approximation.  Such  is  not  so  largely  true  with  the  opera- 
tion advised  later  on  for  use  in  immediate  perineorrhaphy,  for  then 
the  tissues  slide  along  the  silkw^orm  gut  when  stretching  takes 
place  and  the  slack  can  readily  be  taken  up. 

Exacth^  the  same  factors,  it  will  be  seen,  concern  any  interrupted 
suture  repair  when  the  secondary  swelling  takes  place. 

It  is  the  practice  of  some  men  to  delay  repair  for  tw^enty-four 
hours  or  more,  with  the  expectation  that  by  that  time  the  immedi- 
ate swelling  Avill  have  subsided  and  the  patient  be  in  better  condi- 
tion. An  extensive  repair  then  necessitates  an  anesthetic.  By  this 
time,  though  the  primary  sw^elling  has  subsided  somewhat,  the  soft 
mucous  structures  are  still  swollen  out  of  proportion  to  the  parts 


76       THE  GYNECOLOGY  OF  OBSTETRICS 

most  imiDortant  in  the  correct  approximation.  The  muscle  and  fas- 
cia strnctiires  have  thus  not  only  assumed  a  less  proportional  value 
in  size  through  this  swelling,  but  also  have  retracted  more,  so  that 
a  correct  repair  by  the  ordinary  interrupted  suture  is  difficult.  It  is 
also  probable  that  the  tissues  have  in  a  way  lost  some  of  the  ability 
to  produce  primary  union  without  an  excess  of  round-cell  infiltra- 
tion, Avhich  results  in  more  than  the  normal  amount  of  scar  tissue. 

The  antiseptic  action  of  normal  lochia  prevents  infection  of  a 
mild  type,  but  that  possibility^  of  contamination,  which  is  always 
important  in  wounds  elsewhere  in  the  body  left  open  twenty-four 
hours,  is  not  of  such  great  moment  here. 

If  the  delay  in  repair  has  been  absolutely  necessar^^,  on  account 
of  the  patient's  condition,  I  think  it  is  wiser,  when  considered 
wholly  from  the  standpoint  of  perfect  future  results,  to  wait  until 
the  tissues  have  assumed  a  more  normal  condition.  In  fact,  I  prefer 
to  wait  until  a  denudation  has  to  be  done.  It  is  not  often  necessary 
to  put  off  a  repair,  and,  naturally,  each  case  has  to  be  considered 
in  the  light  of  the  particular  circumstances.  The  involvement  of  the 
anal  sphincter  in  the  injury  will  always  necessitate  an  earlier  op- 
eration for  the  comfort  of  the  patient  and  on  account  of  the  atro- 
phy of  the  muscle. 

Sometimes  it  ma}'  be  necessary  to  aim  at  a  partial  improvement 
of  conditions  rather  than  the  ideal  we  desire ;  but  it  stands  to  rea- 
son from  our  knowledge  of  healing  processes  that  the  earlier  the 
approximation  is  done,  provided  we  do  not  propose  to  wait  until 
the  raw  areas  have  healed  by  granulation,  the  more  perfect  will  be 
the  results. 

The  method  used  for  the  immediate  correction  of  the  vaginal  in- 
juries must  depend  wholly  on  the  character  of  these  injuries.  A 
tear  involving  only  the  skin  or  mucous  membrane,  and  which  inter- 
feres in  no  way  with  the  integrity  of  the  floor  or  diaphragm,  needs 
only  a  few  superficial  sutures  for  approximation. 

No  matter  how  slight  the  injury,  it  is  well  in  all  cases  in  which 
there  are  no  contraindications  to  close  the  raw  area,  in  order  to 
avoid  possible  infection.  But  if  for  an}^  reason  it  is  deemed  best  to 
do  no  repair,  nature,  as  a  rule,  favors  rapid  granulation  and  pro- 
tection. 


IMMEDIATE  REPAIRS  77 

Eoi-  perfect  secondai-y  results  in  cases  in  wliicli  the  injury  is 
more  extensive,  it  is  important  to  recognize  the  extent  of  the  tear 
and  use  some  metliod  of  approximation  that  will  unite  in  correct 
ap])ositi()ii  the  c()rresi)()ndini;'  layers. 

The  severe  cases  of  perineal  injui-y  offer  dia.i-iiostic  difficulty 
only  in  determining- their  extensiveness,  it  is  not  an  unconnnon  ex- 
j^erience  to  find,  on  careful  examination,  after  the  blood  from  above 
has  been  teni]iorarily  excluded  by  a  vaginal  pack,  that  the  injury 
has  extended  nmch  farther  up  tiian  was  expected.  In  a  forceps  de- 
livery the  injury  most  frequently  assumes  the  "  Y  "-shaped  form 
already  descri])ed.  Sometimes  the  stem  of  the  '' Y,"  which  repre- 
sents the  injury  to  the  central  tendon,  is  wanting,  on  account  of  the 
stretching  rather  than  tearing  of  the  elastic  tissues  of  the  perine- 
um. Usually,  however,  there  is  at  least  a  skin-rent  in  this  direction. 
Consequently,  unless  the  patient  is  carefully  examined  on  a  table 
in  good  light,  the  injury  higher  up  is  overlooked. 

If  this  injury  occurs  on  both  sides,  the  retraction  of  the  muscle 
fibers  of  the  levator  ani  with  the  contraction  of  the  circular  fibers 
of  the  vaginal  wall  tend  to  elevate  the  "  V  "-shaped  segment  of  the 
vagina.  The  natural  inference  in  such  cases  is  that  the  apex  of  this 
inverted  ''V"  ought  to  be  brought  dowai  by  the  sutures  to  the 
point  that  corresponds  to  the  normal  posterior  commissure.  If  we 
do  this,  we  are  separating  the  surfaces  of  the  pelvic  diaphragm  that 
should  be  approximated  and  are  attaching  the  dorsal  vaginal  wall 
to  the  central  tendon  without  the  interposition  of  any  supporting 
structures.  A  rectocele  very  promptly  develops  when  the  erect  pos- 
ture makes  the  weight  of  the  rectal  contents  bear  on  the  unsupport- 
ed dorsal  vaginal  wall. 

Such  an  injury  should  be  dealt  with  by  pulling  up  out  of  the 
field  this  segment  of  vaginal  wall  and  approximating  beneath  it 
the  levator  ani,  so  that  the  completed  operation  will  place  the  apex 
of  the  "V"  a  little  distance  within  the  vagina,  this  distance  de- 
l^ending  on  the  extent  of  the  injury. 

If  the  repair  is  done  with  interrupted  sutures,  the  lowest  suture 
may  be  placed  first,  and  if  left  untied  and  used  as  a  retractor,  pull- 
ing downward  when  the  next  higher  one  is  placed,  it  is  thus  ])os- 
sible  to  build  u])  the  perineum  from  below.  This  gives  an  idea  of  the 


78       THE  GYNECOLOGY  OF  OBSTETRICS 

position  the  "V"  segment  shonld  norinall}^  occupy.  Then  the  an- 
gles of  the  ''Y"  can  be  closed  above  the  pelvic  diaphragm.  The 
sutures  are  always  tied  from  above  downward.  By  this  method  we 
are  sure  of  obtaining  correct  approximation  of  the  floor  and  dia- 
phragm without  interposing  the  vaginal  wall. 

There  is  a  variety  of  tear  which  occurs  rather  frequently,  but  is 
exceedingly  difficult  to  diagnose  at  the  time  of  labor.  This  is  where 
the  pelvic  diaphragm  gives  way  beneath  the  vaginal  walls  and  the 
pelvic  floor  and  is  not  accompanied  by  superficial  injury.  This  class 
of  defect  explains  some  of  the  cases  where  a  woman  is  told  she  has 
not  been  "torn,"  but  nevertheless  the  relaxed  vaginal  outlet  de- 
velops in  spite  of  the  promises  of  good  results. 

There  is  no  consensus  of  opinion  as  to  the  proper  procedure  for 
correction.  Theoretically,  the  most  desirable  treatment  would  be  to 
lay  open  the  superficial  structures,  and  then  to  approximate  the 
tissues  from  within  outward.  If  the  aseptic  conditions  of  the  sur- 
roundings are  good,  and  there  is  no  contraindication  in  the  pa- 
tient's general  condition,  such  treatment  would  be  by  all  means  the 
most  advisable.  In  the  absence  of  favorable  aseptic  conditions,  the 
surgical  indications  are  for  a  postponement  of  the  repair  to  some 
future  date. 

As  a  rule,  it  is  not  difficult  to  determine  whether  or  not  the  ex- 
ternal sphincter  ani  has  been  injured,  for  the  cleft  is  usually  evi- 
dent down  to,  even  if  not  through,  the  rectal  mucous  membrane.  It 
can  hardly  be  overlooked  if  searched  for  carefully.  The  question  of 
getting  uniformly  good  results  from  the  operation  is  another  mat- 
ter, for  the  average  method  of  repair  with  interrupted  sutures,  es- 
pecially when  of  absorbable  material,  is  often  a  failure. 

My  experience,  covering  a  period  of  years,  with  the  use  of  non- 
absorbable sutures  in  immediate  perineal  repairs  prompted  me  to 
report  my  findings  for  the  California  State  Medical  Society  at 
its  meeting  in  the  spring  of  1911.  The  consciousness  of  the  need 
of  a  better  technique  had  been  present  in  the  minds  of  other  oper- 
ators, for  some  time  after  the  reading  of  my  paper  I  was  pleased 
to  observe  in  the  Journal  of  the  American  Medical  Association  of 
February  1,  1913,  a  paper  by  Dr.  Greer  Baughman,  of  Richmond, 
Virginia,  read  before  the  Medical  Society  of  Virginia  in  October, 


IMMEDIATK  KKPAIIJS  79 

lf)12,  a(lv()('atini>-  i)raeticaUy  the  same  proccMhnc.  l)i-.  Baii^lniiau 
»>iv('S  credit  to  liis  colleas^'ue,  Dr.  (Miai-lcs  R.  Rohiiis,  i'ov  the  sug- 
i!,'esti()ii. 

I  shall  (|U()te  froiii  the  papei"  I  then  read  to  emphasize  the  iiii- 
l)<)i-taiiee  of  a  pi-oeediii-e  that  will  attain  more  satisfactory  results 
than  now  prevail.  In  |)'art  my  paper  was  as  follows : 

"A  proiiiiiient  general  ])ractitioner  in  discussing  perineal  re- 
pairs at  a  society  meeting  made  the  statement  that  he  never  allowed 
any  degree  of  tear  to  go  unrepaired,  for  he  did  not  intend  that  any 
woman  whom  he  confined  could  he  told  that  she  needed  a  perineor- 
rhaphy. That  is  the  feeling  and  practice  of  all  conscientious  ob- 
stetricians, and  yet  when  a  patient  who  has  a  relaxed  vaginal  out- 
let is  told  that  she  has  to  have  a  repair,  she  invariably  tells  you 
that  her  doctor  sewed  her  up  when  the  baby  came  and  also  how 
many  stitches  were  taken.  But  this  only  goes  to  show  that  a  large 
percentage  of  repairs  in  recent  tears  result  in  failure,  and  unless 
the  attendant  can  recognize  early  the  cases  of  failure,  the  patient 
gets  out  of  his  hands  with  a  false  sense  of  security  as  to  her  good 
condition. 

' '  Lately,  due  to  the  rather  large  proportion  of  unsatisfactory 
results  with  the  use  of  the  interrupted  suture,  I  have  been  applying 
the  continuous  mattress  suture  of  silkw^orm  gut  advocated  by  Dr. 
Geo. B.Somers  of  San  Francisco  for  secondarj^  perineorrhaphies." 

M}^  technique  is  as  follows:  Using  a  small  curved  needle  while 
the  edges  of  the  tear  are  being  retracted  with  vulsellum  forceps, 
the  lirst  suture  is  applied  from  side  to  side  in  the  depth  of  the 
wound,  the  tissue  being  finall}^  pushed  back  along  the  untied  stitch. 
The  second  suture  is  applied  in  the  same  w^ay^  above.  In  this  Avay 
one  can  approximate  the  divided  perineal  body  and  prevent  the  re- 
traction of  the  torn  musculature.  While  this  type  of  suture  is  much 
harder  to  use  in  these  immediate  repairs  than  the  interrupted,  on 
account  of  the  rapid  swelling  of  the  parts  and  the  quantity  of  ob- 
scuring blood,  the  advantages  gained  and  the  much  more  satisfac- 
tory results  make  the  extra  care  well  worth  while. 

The  continuous  suture  does  not  constrict  the  circulation  as  does 
the  interrupted.  It  approximates  the  perineal  body  throughout  its 
entire  depth,  and  after  the  edema  and  SAvelling  have  subsided  there 
is  no  slack  on  the  sutures;  oi-,  if  there  is,  it  can  be  taken  up  by 


80       THE  GYNECOLOGY  OF  OBSTETRICS 

pressing  the  tissue  back  along  the  stitch.  If  interrupted  sutures  are 
used,  we  shall  find  after  the  swelling  has  subsided  that  the  swollen 
tissue  in  the  grasp  of  the  suture  has  been  partially  cut  through  and 
that  the  stitch  is  too  loose  to  give  a  perfect  approximation,  and  so 
the  fluids  can  percolate  and  prevent  perfect  primary  union.  If  by 
any  chance  infection  of  the  perineum  has  occurred,  the  insoluble 
continuous  suture  acts  as  a  drain,  and  whatever  swelling  takes 
place  can  be  accommodated  on  the  untied  sutures  without  any  cut- 
ting through  of  the  tissues,  so  that  the  results  are  good.  This  would 
be  impossible  if  the  repair  had  been  done  with  either  absorbable  or 
non-absorbable  interrupted  stitches. 

Sometimes  the  rectal  sphincter  is  injured  and  overlooked,  on  ac- 
count of  the  difficult}^  of  thorough  inspection.  It  is  not  of  such  vital 
importance  if  we  succeed  in  getting  a  good  perineal  bod}^  by  pri- 
mary union.  It  is  not  the  severance  of  the  sphincter-muscle  fiber 
that  is  of  such  moment,  for  that  is  often  done  intentionally  in  fistu- 
la operations  without  bad  effect ;  but  it  is  the  poor  perineal  results 
with  the  retraction  of  the  muscle  layers,  and  the  consequent  lack  of 
ventral  anchorage,  that  allow  the  retraction  and  atrophy  of  the 
rectal  sphincter.  If,  despite  our  failure  to  unite  the  torn  sphincter, 
we  have  succeeded  in  getting  an  otherwise  normal  perineum,  then 
the  muscle  will  not  lose  its  function. 

If  we  consider  the  injured  sphincter  ani  from  the  standpoint  of 
the  fistula  operation,  we  find  that  practically  all  authorities  agree 
that  it  is  the  multiple  or  the  oblique  incisions  of  the  muscle  that  are 
likely  to  be  followed  hj  incontinence. 

In  discussing  the  operation  for  rectal  fistula,  Earle  states :  "  In- 
continence of  feces  may  follow  an}^  of  the  operations  for  fistula, 
but  it  generally  results  from  an  oblique  incision  of  the  sphincter 
muscle,  which  should  always  be  avoided. ' ' 

Fortunately,  in  complete  tears  of  the  perineum  the  sphincter-ani 
muscle  is  torn  through  in  the  median  line  on  account  of  its  anatom- 
ical relations  to  the  central  tendon  and  coccyx.  An  oblique  tear  is 
hardly  likely  to  occur,  for  the  force  required  to  accomplish  this 
would  more  naturally  expend  itself  in  separating  the  whole  sphinc- 
ter along  the  cleavage  line  between  it  and  the  rectal  sling  of  the 
pelvic  diaphragm,  so  that  the  rectal  orifice  with  its  sjDhincter  mus- 


nrMEDTATE  REPAIRS  81 

cles  would  be  drawn  to  one  or  tlie  otlier  side  and  left  uninjured.  It 
is  this  anatomical  relation  which  accounts  for  the  possibility  of  ol)- 
taining  good  fecal  conti'ol  under  the  conditions  described. 

Naturally,  the  ends  of  the  torn  sphincter  ani  have  a  more  ragged 
character  than  tlu'  cut  nuiscle  of  the  fistula  operation,  and  perfect 
continence  may  not  conw  until  the  scar  tissue  has  contracted  per- 
manently. 

For  the  purposes  of  repair,  every  perineal  injury  must  be  stud- 
ied individually.  In  extensive  "  Y  "-shaped  injuries,  the  continu- 
ous mattress  suture  used  alone  is  difficult  to  apply.  In  the  majority 
of  cases,  it  is  easier,  and  perhaps  wiser,  to  approximate  the  upper 
limits  of  the  injury  with  interrupted  sutures,  starting  the  continu- 
ous suture  at  the  point  just  above  the  levator-ani  muscle.  It  is  from 
here  outward  that  the  important  structures  lie,  the  approximation 
of  which  is  essential  to  good  results.  There  is  no  reason,  however, 
wdiy  the  w^hole  repair  cannot  be  done  with  the  continuous  suture. 
It  usually  needs  four  sutures  to  properly  unite  an  extensive  injury 
so  that  the  sutures  can  be  used  alternately  in  the  lateral  tears, 
which  are  naturally  less  than  half  the  depth  of  the  external  por- 
tion. The  only  disadvantage  is  the  difficulty  of  insertion  and  the 
length  of  suture  to  be  removed.  The  tissues,  however,  remain  soft 
for  some  time  after  confinement,  so  that,  as  a  rule,  the  sutures  are 
easily  withdrawn. 

It  is  not  necessary,  in  fact  I  think  it  is  sometimes  unwise,  to  ap- 
proximate with  any  buried  absorbable  suture  the  sphincter  ani,  if 
injured,  for  the  continuous  suture  can  easily  be  made  to  accom- 
plish the  same  result. 

After  three  more  years'  experience  in  using  this  method  of  re- 
pair, I  feel  that  it  is  the  only  reliable  procedure  in  such  w^ork.  As  a 
proof  of  the  results,  I  had  a  counterclaim  in  a  suit  for  fees  against 
a  patient  who,  at  the  instigation  of  a  general  practitioner,  was 
threatening  suit  for  having  given  her  too  good  a  perineum.  This 
physician  examined  the  patient  for  the  first  time  eight  months 
after  confinement,  and  on  the  witness-stand  testified  to  finding  an 
ulceration  of  the  vulva  and  being  unable  to  make  a  digital  exam- 
ination. Yet  he  was  positive  that  his  inability  to  make  an  examina- 
tion was  due  to  a  too  perfect  perineorrhaphy  rather  than  to  the  local 


82       THE  GYNECOLOGY  OF  OBSTETRICS 

conditions  and  the  vaginismus  he  testified  were  present.  My  own 
records  show  an  examination  of  the  patient  two  months  after  con- 
finement, when  the  perineum  was  found  in  perfect  condition,  and 
examination  Avith  the  ordinary  speculum  offered  no  difficulty, 
though  even  two  months  previous  to  labor  the  vaginal  canal  had 
been  extremely  small,  only  admitting  a  virgin  speculum. 

I  do  not  believe  that  it  is  possible  in  a  perineorrhaphy  at  the 
time  of  labor,  especially  in  a  case  in  which  there  is  no  denudation 
done  and  no  loss  of  tissue,  to  get  any  smaller  vaginal  canal  than 
formerly.  Anatomically,  it  is  out  of  the  question  to  build  up  a 
perineal  body  beneath  the  mucous  membrane  better  than  nature 
originally  provided.  With  sloughing  of  mucous  membrane  and  later 
scar-tissue  contraction,  it  is  possible  to  get  a  too  narrow  vaginal 
canal,  but  such  a  condition  did  not  exist  in  the  case  mentioned. 

In  this  chapter  I  do  not  consider  in  detail  the  continuous  mat- 
tress suture  advised,  for  it  will  be  spoken  of  under  operations  for 
secondary  repair. 


CURETTAGE 

A  S  AN  accoiiipaiiiiiu'iit  of  pchic  plastic  work,  a  curettage  of 

/^      the  uterus  is  of  value,  unless  there  is  a  latent  infection  in 

r — m     tlie  uteins  oi-  tul)es.  By  the  removal  of  the  mucous  mem- 

-^    -^-  ])ran(\  we  deplete  tlie  circulation  of  the  uterus  somewhat, 

and  give  that  organ  also  a  chance  to  reproduce  a  new  membrane 

under  the  favorable  condition  of  rest  in  bed. 

in  cases  of  sus])ected  malignancy  we  have  in  a  careful  curettage, 


This  iJlustratioii  is  from  a  frozen  section  of  endome- 
trium removed  by  curette.  Decidual  wandering  cells 
are  present  in  large  numbers  in  the  tissue.  There  is 
marked  round-cell  infiltration.  The  possibility  of  mis- 
taking such  a  section  for  chorioepithelioma  is  great. 
These  cells  normally  persist  in  the  uterine  mucosa  for 
some  time  following  pregnancy.  The  tissue  lacks 
the  elements  of  villi  formation  with  the  blood  cavity 
association   that    is    indicative    of   chorioepithelioma. 

done  to  obtain  tissue  for  microscopial  examination,  a  valuable 
aid  to  diagnosis,  and  in  polyp  formations  of  the  mucous  membrane 
it  is  an  essential  treatment.  But  outside  of  these  indications,  un- 
less done  for  the  purpose  of  emptying  a  uterus  of  abnormal  struc- 
tures, such  as  a  hydatid  mole,  or  retained  products  of  conception, 


84       THE  GYNECOLOGY  OF  OBSTETRICS 

the  curettement  as  a  treatment  by  itself  is  practically  seldom  in- 
dicated. 

The  more  skilled  the  physician  is  in  diagnosis,  the  less  frequent- 


An  enlargement  of  the  preceding  section  that  shows  more  in 
detail  the  decidual  wandering  cells.  The  comparison  with  the 
higher  magnification  of  the  vaginal  chorioepithelioma  section 
is  of  interest.  The  wandering  cells  and  villi  elements  are  always 
found  in  the  mother 's  structures,  on  account  of  the  close  re- 
lation of  the  fetal  elements  to  the  blood  stream.  Under  normal 
conditions,  these  elements,  being  fetal,  are  destroyed  by  the 
mother.  They  have  no  tendency  to  reproduction,  and,  even  if  in 
excess  and  increasing,  will  disappear  with  the  improved  resis- 
tance of  the  mother.  Ludwig  Pick  believes  that  the  villi  ele- 
ments (the  Langhan's  cells  and  syncytium)  may  produce  wan- 
dering cells,  or  vice  versa,  though  one  probably  predominates 
at  the  start.  If  continued  scrapings  of  the  mucous  membrane 
show  the  persistence  of  these  wandering  cells  for  a  consider- 
able time,  he  advises  the  removal  of  the  uterus.  In  the  majority 
of  cases,  however,  the  fetal  elements  disappear  in  a  few  months 
following  a  termination  of  conception. 

ly  does  he  resort  to  curettage,  for  he  learns  hy  experience  that  the 
group  of  symptoms  supposed  to  indicate  an  endometritis,  so- 
called,  is  nothing  more  than  an  indication  of  pelvic  congestion  that 


CURETTA(JE  85 

lias  as  its  orii^iii  sonic  patliolo.i^ical  coiKlilioii  ol'tcii  situated  outside 
of  the  uteiiiic  cavity. 

Curettage  doue  at  the  time  of  llie  eoirection  of  i)eivie  jjatlioiogy 
is  in  nou-iufec'tious  cases  a  wise  niocedui-e,  for  the  depletion  of  the 
utei'us  acconiplislied  is  of  heiielit.  In  cases  associate(l  with  acute 
iiilVctioiis  it  is  an  unwise  treatment,  as  we  open  up  new  lymi)hatic 
si)aces  and  l)reak  down  nature's  protections.  In  cases  of  miscar- 
riage many  writers  i-econuuend  non-interference,  even  though  the 


A  polyp  of  the  cervix.  The  forceps  grasps 
the  cervix  above  the  tiimor. 

possi])ility  of  hemorrhage  or  sapremic  infectioii  is  always  a  factor 
to  ])e  considered. 

The  serrated  curette  of  Kelly  is  by  far  the  most  useful  type  of 
instrument  to  employ,  for  with  it  the  mucous  memhrane  can  he  re- 
moved in  larger  segments,  and  this  is  an  advantage  if  microscopi- 
cal examination  is  indicated.  The  removal  of  the  membrane  also 
can  be  done  more  thoroughly  witliout  as  much  danger  of  pene- 
trating the  uterine  walls.  The  main  purpose  to  accomplish  in  the 
operation  is  to  make  sure  of  a  thorough  curetting  of  the  cavity  so 
as  to  leave  no  shreds  of  membrane  incompletely  separated.  Other- 
wise, we  have  the  factors  present  favorable  for  a  sapremic  infec- 
tion. The  possibilities  for  harm  from  the  curette  in  tlie  unskilled 


86 


THE  GYNECOLOGY  OF  OBSTETRICS 


A  section  from  a  beginning  cervical  polyp,  removed  for  diagnosis. 
The  condition  present  is  one  of  chronic  inflammation  accom- 
panied by  marked  increase  of  the  squamous  cells.  The  unbroken 
line  of  demarcation  between  the  epithelial  covering  and  the  cervix 
beneath  is  characteristic  of  non-malignancy.  Such  proliferation 
of  the  epithelial  layer  is  often  found  in  benign  polyps. 


This  specimen  shoAVS  a  non-malignant  polyp  of  the  cervix 
in  which  many  of  the  glands  are  cystic.  The  typical  strati- 
fied squamous  epithelial  covering,  and  the  normal  struc- 
ture of  the  glands  as  shown  in  detail  in  the  higher  magni- 
fication, are  evidence  of  a  non-malignant  growth. 


CURETTAGE 

J 


87 


A  section  of  a  cervical  polyp  that  shows  glaud  prolifer- 
ation with  cystic  development.  The  round-cell  infiltration 
indicates  an  inflammatory  origin.  There  are  none  of  the 
marks  of  malignancy. 


This  section  shows  in  detail  the  gland  structure  foun( 
a  cervical  polyp.  The  glands  are  somewhat  cystic.  Tlie 
cylindrical  cells  lining  the  cavities  are  uniform,  with  no 
abnormal  heaping  and  with  intact  basement  membrane. 
The  apparent  piling  of  the  cells  in  one  cavity  is  due  to  the 
fact  that  connection  with  the  larger  cyst  is  at  an  acute 
angle,  so  that  the  cells  have  been  sectione<l  transversely. 


88       THE  GYNECOLOGY  OF  OBSTETRICS 

hand  has  been  too  well  emphasized  in  all  text-books  to  require  en- 
largement here.  The  continual  recurrence  of  reports  of  perforated 
uteri  in  careless  hands,  and  even  occasionally  by  skilled  operators, 
ought  to  be  sufficient  to  emphasize  the  great  importance  of  doing 
such  work  with  the  greatest  delicacy. 

For  the  purpose  of  washing  out  the  debris,  the  irrigation  of  the 
uterus  following  the  scraping  has  nothing  to  condemn  it,  provided 


Section  of  tissue  removed  by  curette  for  diagnosis.  This 
is  the  character  of  tissue  most  commonly  taken  for 
malignancy.  The  apparent  irregularity  of  the  lumen  is 
not  due  to  a  heaping  up  of  epithelial  cells,  but  to  an  ir- 
regular proliferation  of  the  stroma  between  the  glands. 
The  condition  is  the  result  of  an  inflammatory  x>rocess. 

we  bear  in  mind  the  ease  with  which  any  solution  under  pressure 
may  be  forced  through  the  tubes  into  the  abdomen,  and  provided 
our  asepsis  is  perfect.  The  more  usual  procedure  of  applying  tinc- 
ture of  iodine,  carbolic  and  alcohol,  or  other  antiseptic  or  caustic, 
may  be  wise  if  we  suspect  an  infection,  but  can  hardly  be  advocated 
as  essential,  or  even  of  value,  in  clean  cases,  in  the  light  of  our 
present  knowledge  of  endometritis  and  our  methods  of  asepsis. 


CURETTAGE  89 

Tf  we  arc  certain  that  the  cavity  is  clean  and  smooth, that  tlio  drain- 
age will  not  be  disturbed  by  our  other  opei-ative  ])r()cediires,  and 
that  our  asepsis  is  good,  there  is  not  much  to  be  accomplished  by 
one  internal  application  to  the  uterine  cavity. 


This  Mgher  magnification  of  the  preceding  section 
shows  that  the  epithelium  lining  the  gland  Imnen 
is  regular,  with  the  basement  membrane  intact — 
findings  which  speak  against  a  malignant  growth. 


CERVIX  OPERATIONS 

OF  THE  j)lastic  operations  in  the  pelvis,  none  have  reached 
a  greater  degree  of  simplicit}^  in  the  number  of  procedures 
than  those  upon  the  cervix.  Since  the  paper  of  Emmet,  in 
1874,  first  emphasized  the  fact  that  so  many  supposed  ul- 
cerations were  but  the  exposure  of  the  mucous  membrane  as  a  re- 
sult of  injur}^,  and  suggested  the  method  he  practiced  for  correc- 
tion, practically  no  change  has  taken  place  in  the  operation  for 
repair.  Tait  said  of  the  Emmet  trachelorrhaphy  that  "we  can't 
modify  the  operation;  we  can't  change  it,  for  it  is  perfect — perfect 
in  its  method,  and  perfect  in  its  results. ' ' 

In  this  monograph,  which  deals  mainly  with  the  injuries  of  par- 
turition and  the  resulting  inflammations,  I  shall  consider  in  detail 
only  the  so-called  low  amputation  and  the  Emmet  repair. 

The  high  ami^utation,  Avhich  means  the  cervix  removal  at  or 
above  the  vaginal  junction,  and  which  depends  upon  the  vaginal 
mucosa  for  the  covering  of  the  uterine  stump,  has  no  place  in  minor 
surgery.  The  consensus  of  opinion  is  that  this  operation  is  often 
attended  by  more  shock  than  even  a  hysterectomy.  It  is  not  the  op- 
eration of  choice  in  a  malignant  condition  of  the  cervix,  unless  we 
are  absolutely  certain  that  the  growth  is  only  superficial.  Any 
question  of  a  more  than  superficial  involvement  demands  a  hys- 
terectomy as  a  necessary  precaution.  If  for  any  reason  a  hysterec- 
tomy is  refused  or  is  impossible,  the  growth  destruction  by  the 
actual  cauter}^  is  more  desirable  than  cutting  into  a  malignant  cer- 
vix and  thus  opening  up  fresh  channels  for  the  cancer-cell  reinocu- 
lation.  I  am  inclined  to  think  that  in  the  very  early  stages  of  epi- 
thelioma, and  possibly  in  some  other  cervical  conditions,  the  use 
of  the  carbon-dioxide  freezing  may  offer  just  as  satisfactory  re- 
sults as  it  does  in  epithelioma  and  other  growth  formations  of  the 
skin. 

Outside  of  conditions  of  malignancy,  there  is  practically  no  pa- 
thology necessitating  the  high  amputation.  The  low  amputation,  on 


CP]RVIX  OPEFiATlOXS 


91 


account  of  the  i-ciuoval  of  a  ccftaiii  aiiioiiut  of  tissue  as  well  as  by 
the  I'avorahlc  retrooradc  process  stai'ted,  takes  eare  of  even  an 
cxc('ssi\'('ly  lai-i;'e  cervix,  so  that  little  is  o'aiiied  by  the  lii^li  opera- 
tion. If  there  is  any  occasion  I'oi'  <'lioice,  the  consideration  should 
lie  between  a  hysterectomy  and  the  hi,i;li  amputation  ratlier  than 
between  the  hii2,-h  and'tlie  low  amputations. 

'riiere  has  been  much  discussion,  especially  in  tiie  Uei-man  liter- 
ature, of  the  effect  of  the  hi^h  cervical  amputation  on  prej^-nancy, 
and  the  opinions  have  been  faii'ly  evenly  divided  as  to  the  possi- 


An  irregularly  lacerated  cervix.  Both  lips 
are  markedly  hypertrophied. 

hility  of  a  fibrous  ring  resulting  that  would  interfere  seriously 
with  lal)or.  Some  contend  that  their  experience  has  showm  a  rapid 
ending  of  the  first  stage  in  the  majority  of  cases.  On  the  other 
hand,  the  tabulated  results  of  cases  reported  seem  to  show  a  much 
greater  increase  in  the  tendency  to  abortion  as  well  as  a  marked 
reduction  in  fertility — after-effects  not  found  in  trachelorrhaphy 
or  the  low  amputation.  Again,  at  operation  severe  secondary  hem- 
orrhage occurs  in  over  five  per  cent  of  the  cases. 

The  simple  repair  of  the  cervix  was  designed  by  Emmet  when  he 
had  his  attention  drawn  to  the  true  pathology  back  of  the  so-called 
"ulceration  of  the  cervix."  He  showed  that  this  supposed  uleera- 


92       THE  GYNECOLOGY  OF  OBSTETRICS 

tion  was  in  reality  the  turning  out  of  the  normal  lining  of  the  cer- 
vical canal,  as  a  result  of  lateral  tears  at  childbirth.  The  healing, 
taking  place  by  the  formation  of  granulations, deposited  scar  tissue 
in  the  angles.  Superimposed  on  that  came  the  erosions  and  result- 
ing inflammation,  as  the  consequence  of  circulatory  disturbance 
and  friction.  In  order  to  correct  this  condition,  he  removed  a 
wedge-shaped  segment  of  tissue  from  each  angle  that  marked  the 
site  of  the  original  injury,  but  left  the  canal  untouched.  He  then 
approximated  the  raw  areas.  Thus,  practically,  he  reproduced  the 
original  injury  and  turned  back  into  the  canal  what  was  the  nor- 
mal lining. 

The  best  way  to  judge  the  extent  of  the  denudation  required  is  to 
grasp  each  lip  of  the  cervix  with  a  single  hook  or  a  vulsellum  for- 
ceps and  hold  them  together.  One  will  then  readily  see  the  amount 
of  tissue  requiring  removal  from  the  angles.  The  area  is  outlined 
by  an  incision,  and  at  the  same  time  the  width  of  the  cervical  canal 
is  marked  off.  The  denudation  within  these  lines  is,  as  a  rule,  more 
readily  done  by  making  first  a  lateral  incision  on  each  side  in  the 
angle  deep  enough  to  reach  below  the  scar  tissue.  The  sides  of  both 
lips  are  then  denuded  with  knife  or  scissors,  as  is  most  convenient, 
keeping  well  beneath  the  scar  formation,  since  it  is  important  that 
all  the  scar  tissue  should  be  removed,  as  that  is  largely  the  basis 
for  the  pathology. 

Each  angle  is  united  by  three  or  more  interrupted  sutures.  The 
first  suture  is  inserted  at  a  point  about  an  eighth  of  an  inch  outside 
the  denuded  area  in  the  vaginal  portion  of  the  ventral  lip  on  the 
patient's  right  side.  It  passes  under  the  raw  area  at  right  angles  to 
the  canal,  exiting  at  the  edge  of  the  undenuded  cervical  strip.  It  is 
then  reinserted  at  a  corresponding  point  on  the  undenuded  portion 
of  the  dorsal  lip,  passing  beneath  the  raw  area  again  at  right 
angles  to  the  canal  to  exit  at  a  point  corresponding  to  the  starting- 
point  on  the  vaginal  mucous  membrane.  This  suture  must  be  placed 
well  in  the  depth  of  the  angle,  in  order  to  prevent  a  gap  and  control 
the  bleeding.  About  a  quarter  of  an  inch  externally,  the  second 
suture  is  placed  in  the  same  manner,  and  so  the  third,  and,  if  neces- 
sary, a  fourth.  The  procedure  is  repeated  on  the  patient's  left  side, 
the  sutures  being  inserted  from  right  to  left  on  the  dorsal  lip  and 


CERVIX  OPERATIONS  93 

from  left  to  Ti,i;-lit  on  the  vciitfal ;  siu-li  placiii.i;-  of  the  sutures  l)i-mgs 
tlic  kuots  ou  tlic  vas>,inal  surface. 

Usually,  the  six  or  eijj;-lit  sutures  are  inserted  before  any  ai'e  tied, 
thoiig'li  if  bleeding-  is  profuse  the  phieiu.L;-  and  t>in,i;-  ol'  the  first  ou 
each  side  will  conti-ol  that  and  pei-iiiit  hettcM-  vision  while  the  other 
sutures  are  being-  placed.  Before  tying-  any  sutures  it  is  inii)ortant 
to  make  sure  that  there  are  no  blood-clots  left  in  the  angles  to  pre- 
vent primary  union. 

When  the  sutures  are  all  placed  and  tied,  the  cervix  should  jn-e- 
sent  a  normal  contour  with  a  single  line  of  approximation  extend- 
ing out  on  either  side  of  the  os,  running  over  the  summit  to  the  base 
in  the  median  line. 

Some  operators  prefer  to  remove  the  strip  of  tissue  in  each 
angle  in  one  wedge-shaped  piece  Avithout  making  any  transverse 
incision.  Left-handed  operators,  or  even  some  right-handed  opera- 
tors, may  prefer  to  apply  the  sutures  in  the  reverse  order  by  start- 
ing the  stitch  on  the  right  side  on  the  ventral  lip,  on  the  left  side  on 
the  dorsal.  The  main  factors  to  be  borne  in  mind  are  the  necessity 
for  the  complete  removal  of  scar  tissue,  and  the  application  of  the 
sutures  so  as  to  place  the  knots  on  the  vaginal  side  of  the  cervix. 

This  operation  on  the  cervix,  wdien  thoroughly  understood,  is  not 
one  which  can  be  considered  difftcult,  and  yet,  to  get  good  results, 
it  is  essential  that  it  should  be  done  with  care.  The  number  of  cases 
that  one  sees  in  Avhich  broad  or  irregular  scars  are  found  follow- 
ing trachelorrhaphy  is  surprising.  Sinus  formations  between  the 
sutured  points  are  also  frecpient.  Both  these  defects,  on  account 
of  the  remaining  irritation,  continue  the  development  of  the  cyst 
formation,  and  therefore  necessitate  a  secondary  plastic  operation. 

The  difference  in  the  value  between  trachelorrhaphy  and  the  low 
amputation  is  one  wholly  of  the  amount  of  tissue  removed.  Of  the 
low  amputation  there  are  several  types,  all,  however,  having  as 
their  purpose  the  removal  of  a  certain  amount  of  tissue  from  the 
ventral  or  dorsal  lip,  or  both,  as  well  as  the  scar  tissue  in  the  an- 
gles, and  at  the  same  time  the  preserving  of  a  patulous  canal. 

It  is  much  easier  to  obtain  a  good-looking  result  from  the  flap 
type  of  operation  devised  by  Schroeder  than  from  the  "cone  and 
mantle  "  operation  of  Simon.  It  is  by  no  means  easy  to  judge  the 


94       THE  GYNECOLOGY  OF  OBSTETRICS 

size  of  the  canal  flap,  or  so-called  cone,  in  relation  to  the  portion  of 
the  cervix  removed.  If  the  cone  is  too  large,  it  will  later  protrude 
and  give  a  margin  of  everted  mucous  membrane  surrounding  the 
OS  when  the  remainder  of  the  cervix  has  undergone  its  normal  in- 
volution. The  Simon  operation  is  also  advisable  only  when  the  cer- 
vical canal  mucous  membrane  is  healthy  and  the  cervix  itself  is 
thick  and  hard. 

The  simplest  operation,  and  the  one  giving  the  best  cosmetic 
results,  and  best  adapted  where  only  a  moderate  amount  of  tissue 
removal  is  required,  consists  first  of  two  lateral  incisions  carried 
well  below  the  scar  tissue  in  the  angles.  Then,  with  a  knife,  or  often 
better  with  the  scissors,  as  much  as  seems  desirable  of  the  upper 
portion  of  the  ventral  and  dorsal  lips  is  removed,  but  at  least 
enough  to  get  below  the  everted  mucous  membrane  and  the  cyst 
formation.  If  this  section  of  the  cervical  lip  is  extensive,  it  is  well 
to  make  either  the  incision  somewhat  wedge-shaped  or  to  under- 
mine slightly  the  vaginal  mucosa,  in  order  to  approximate  more 
easily  the  cervical  and  vaginal  mucous  membranes.  This  approxi- 
mation is  done  with  two  interrupted  sutures  about  the  width  of  the 
canal  apart,  care  being  taken  when  passing  the  needle  through  the 
cervical  mucosa  to  go  deep  enough  to  include  some  muscle  tissue 
and  thus  avoid  the  tearing  out  of  the  suture  when  tying.  In  all  cer- 
vical work  the  general  surgical  principle  of  working  from  below 
up,  so  that  the  blood  will  not  unnecessarily  obscure  the  field,  should 
be  observed. 

Having  obliterated  b}^  the  sutures  both  the  denuded  areas  on  the 
lips,  it  is  then  possible  to  determine  the  amount  of  tissue  that  it 
is  necessary  to  remove  from  the  angles  of  the  cervix  in  order  to 
get  rid  of  the  scar  tissue  and  obtain  an  even  and  accurate  approx- 
imation. This  removal  is  done  just  as  in  the  ordinary  repair. 
Three  or  four  sutures  on  each  side,  placed  in  the  same  wa}^  as  in 
trachelorrhaphy,  complete  the  operation.  The  bleeding  may  be 
rather  profuse  at  first,  especially  if  the  tissue  removal  is  extensive. 
As  a  rule,  this  bleeding  is  readily  controlled  by  the  first  sutures 
applied.  If,  how^ever,  it  comes  from  a  vessel  in  the  exposed  lateral 
areas,  a  hemostat  can  be  applied  until  it  is  time  to  place  the  first 
sutures  in  the  angles.  AYith  these  properly  placed  and  tied,  there 


CET^VTX  OlM^RATTOXS  95 

is  no  fni-tlicr  ti'<)iil)l('  .'iiid  no  necessity  of  li,i;atiii,t;'  any  iiidiN'idiial 
\'essel. 

It  is  well  ill  all  operations  on  the  cefX'ix  to  nse  clironiic  ,!^iit,  for 
even  as  late  as  the  tenth  day  secondai'X'  hleedini;'  has  heen  ri-ecjuent- 
ly  reported,  pi-ol)al)ly  as  a  result  of  the  too  eai'lv  disappearance  of 
the  suture  material.  'As  most  of  tliese  eases  are  associated  with 
perineal  repair,  it  is  wiser  to  use  a])sorbable  sutures,  and  thus 
avoid  the  early  stretching'  of  the  i)eriiieum  necessary  for  the  re- 
moval of  non-absorbahle  niatei'ial.  It  is  wise,  also,  to  ])lace  a  loose 
wick  of  gauze  within  the  cervical  canal  in  all  cases  of  amputation, 
in  order  to  i^revent  the  gluing  together  of  the  lips  and  the  inter- 
ference Avith  drainage.  If  this  gauze  is  left  sufficiently  long  to  pro- 
trude from  the  vagina,  or  a  ligature  is  tied  to  it  for  the  same  j)ur- 
pose,  the  gauze  can  be  readiW  removed  by  the  nurse  at  the  end  of 
thirty-six  or  forty-eight  hours. 

In  the  Simon  operation  an  attempt  is  made  to  remove  in  one 
section  a  wedge-shaped  piece  extending  across  the  whole  width  of 
the  cervical  lip,  usually  after  the  primary  lateral  incisions  have 
been  made.  It  is  then  necessary  to  form  on  the  inner  surface  of  the 
wedge  a  flap  of  mucous  membrane  for  the  cervical  canal.  Here  it  is 
that  the  difficulty  is  presented  of  judging  the  amount  of  tissue  to 
l)e  removed  and  the  shape  of  the  wedge,  so  as  to  obtain  a  nice  ad- 
justment without  a  redundancy  of  the  canal  mucous  membrane. 

Schroeder's  single-flap  method  modifies  the  operation  by  making 
an  incision  at  right  angles  to  the  cervical  canal  across  both  lips, 
separated  by  the  first  incisions,  to  a  depth  sufficient  to  get  below 
the  cystic  portion,  and  then  removing  a  section  of  tissue  at  that 
depth  across  the  whole  cervix  parallel  to  the  cervical  canal.  This 
procedure  makes  a  somewhat  thinner  flap  of  the  lips,  so  that  they 
can  be  folded  upon  themselves  in  approximating  the  nmcous  edges. 
In  both  modifications  the  suturing  is  identical. 

In  all  cervical  operations  the  first  essential  is  to  leave  a  cervical 
canal  as  normal  as  possible.  In  order  to  do  this  and  prevent  a  com- 
plete closure,  it  is  necessary  to  leave  on  at  least  one  lip  a  sufficient 
amount  of  undenuded  mucous  niemln-ane.  It  is  important  to  make 
sure  that  the  canal  is  sufficiently  patulous  at  the  os,  so  that  the 
caliber  is  the  same,  or  at  least  not  greater,  within  the  cervix.  If  the 


96       THE  GYNECOLOGY  OF  OBSTETRICS 

reverse  is  true,  normal  drainage  is  interfered  with  and  future  pos- 
sibilities for  trouble  offered. 

Every  text-book  of  gynecology  contains  detailed  descriptions, 
with  illustrations,  of  the  cervical  operations,  at  least  those  advo- 
cated by  the  individual  writers,  and  it  is  not  the  purpose  of  this 
chapter  to  repeat  what  is  already  in  every  doctor's  library,  but 
rather  to  emphasize  the  procedures  which  are  most  applicable,  es- 
pecially from  the  standpoint  of  the  details  that  experience  has 
made  pertinent. 


SYMPTOMS  AND  DIAGNOSIS  OF  THE  RELAXED 
VAGINAL  OUTLET 

Tl  1 1^]  diagnosis  of  a  relaxation  of  tlie  vaginal  outlet  ought  to 
]) resent  no  difficulty.  The  reason  that  so  many  of  these  con- 
ditions are  neglected  is  probably  due  not  so  much  to  the 
lack  of  recognition  of  the  injury  as  it  is  to  a  poor  apprecia- 
tion of  the  importance  of  correct  support  to  the  woman's  health. 
A  history  of  the  character  of  the  labors  with  a  review  of  the  pres- 
ent symptoms  will  almost  always  direct  attention  to  the  possibili- 
ties, and  a  careful  examination  will  readily  confirm  what  we 
suspect.  In  making  this  examination,  however,  it  is  important  to 
use  an  examining-table  instead  of  a  lounge  or  bed,  for  the  posture 
of  the  patient  may  obscure  the  gravity  of  some  of  the  pathology. 
By  noting  the  changes  from  the  normal  in  the  vulva,  such  as  the 
increase  of  distance  between  the  vestibule  and  anus,  the  flattened 
appearance  of  all  the  parts  in  contrast  to  the  contour  of  an  unin- 
jured outlet,  with  the  thinning  out  of  the  perineal  bod}^  itself,  the 
diagnosis  is  possible.  If,  with  these,  the  cystocele  and  rectocele  pro- 
trude, there  can  be  no  doubt  of  the  condition.  However,  one  of  the 
simplest  and  best  methods  of  judging  the  degree  of  relaxation  is 
to  ask  the  patient  to  bear  down.  This  forcing  down  of  the  pelvic 
contents  in  cases  with  no  diaphragm  support  causes  a  rolling-out 
of  the  vaginal  septa  and  a  reproduction  in  a  more  marked  degree 
of  the  condition  that  is  present  when  the  patient  is  standing.  Es- 
pecially is  this  procedure  valuable  in  cases  where  the  diaphragm 
is  injured  but  the  central  tendon  remains  fairly  intact,  for  in  such 
cases  the  outward  signs  are  often  not  marked.  It  is  surprising 
sometimes  to  find  to  what  a  degree  the  cystocele  and  rectocele  will 
protrude,  when  on  simple  inspection  their  existence  may  have  been 
doubted. 

Again,  with  the  finger,  or  better  both  index  fingers,  inserted  in 
the  vagina  and  pressure  exerted  downward,  in  the  lateral  aspects 
of  the  canal,  Ave  can  readily  judge  of  the  degree  of  relaxation, 


98       THE  GYNECOLOGY  OF  OBSTETRICS 

and  with  more  gentle  pressure  can  palpate  the  location  of  the 
injury. 

The  third  method  of  judging  the  degree  of  laxity  is  to  request 
the  patient  to  contract  the  pelvic  diaphragm;  with  the  finger  in 
the  vagina  against  the  perineum,  we  can  readily  determine  the 
amount  of  muscle  tissue  still  functionating.  In  a  marked  relaxa- 
tion, what  the  patient  ac- 
complishes by  this  procedure 
is  the  contraction  of  the 
fibers  behind  the  rectum. 
This  brings  the  structures 
ventral  to  the  levator  ani 
forward  as  a  whole,  instead 
of  contracting  the  perineum 
directly  beneath  the  fingers. 
In  a  normal  individual  this 
demonstration  will  readily 
show  the  distribution  of  the 
levator-ani  muscle. 

These  three  methods  are 
not  only  useful  in  making  a 
diagnosis  of  the  degree  of 
relaxation,  but  will  give  us 
an  idea  of  the  value  of  our 
repair  work  when  the  patient 
returns  later  for  examina- 
tion. When  the  operation  is 
completed,  and  before  the 
patient  leaves  the  table,  it  is 
easy  by  palpation  to  demon- 
strate the  correctness  of  the  work  done.  If  by  chance  the  patient 
happens  to  vomit  or  cough,  we  are  given  an  interesting  demonstra- 
tion of  the  value  of  our  diaphragm  repair.  If  perfect,  then  the  con- 
traction of  the  muscle  pulls  up  the  dorsal  vaginal  wall  snugly  against 
the  ventral  and  prevents  the  rolling-out  of  the  structures  that  took 
place  before.  Of  course,  there  is  always  a  transmission  of  the 
pressure  impulse  from  above,  which  causes  a  protrusion  of  the 


This  patient  submitted  to  a  trachelorrhaphy  and 
perineorrhaphy  two  years  ago.  From  external 
appearance,  the  results  are  good,  but  careful 
examination  shows  that  the  diaphragm  offers  no 
support.  The  illustrations  that  follow  show  the 
degree  of  relaxation  and  the  methods  used  in 
determining  the  value  of  the  support. 


TIIK  KKLAXKI)  VAGINAL  OUTLKT 


!)9 


soft  parts  as  a  whole,  hut  the  rcphiccd  muscle  ('h)ses  the  vagina  and 
prevents  auv  protrusion  of  the  septa  hevoud  the  hody  line.  Tf  any 
does  take  place,  it  s|)eaks  I'oi-  a  poor  repair,  which,  hy  just  such 
inipuLses,  is  i;radually  sti'etched  out  later  on. 

W'hih'  exaniinini;'  a  patient  with  a  I'elaxed  va.ninal  outlet,  it  is 
wise  to  grasj)  tiie  cervix  with  a  vulselluin  and  make  traction  down- 
ward, for  thus  we  are  enabled 
to  judge  more  readily  of  the 
level  at  which  the  cei'vix  lies 
and  can  better  determine  the 
amount  of  sui)p()rt  necessary 
in  the  venf  ral  and  dorsal  va- 
ginal walls.  This  procedure 
also  enables  us  to  estimate  the 
shape  and  size  of  the  uterus 
and  its  exact  position,  thus 
doing  away  with  the  use  of  a 
uterine  sound.  As  an  instru- 
ment for  diagnosing  the  posi- 
tion or  the  size  of  the  uterus, 
the  intrauterine  sound  should 
have  no  place  in  any  physi- 
cian's hands,  and  the  more  the 
instrument  is  used  the  poorer 
gynecologists  we  can  acknowd- 
edge  ourselves  to  be. 


1 

\ 

^B  ^'^^I' 

( 

1 

/"' 

A  separation  of  the  labia  shows  the  prominence 
of  the  ventral  vaginal  wall  with  a  portion  of 
the  rectocele.  In  this  case  the  greatest  injury 
to  the  diaj^hragm  is  in  the  left  sulcus.  Evident- 
ly no  attempt  was  made  to  approximate  the 
diaphragm  at  time  of  the  perineorrhaphy,  as 
judged  by  the  degree  of  levator-ani  retraction. 


There  is  probably  no  phys- 
ical defect  that  gives  such 
variety  in  its  symptomatology 
as  does  the  relaxed  vaginal 
outlet  with  its  resulting  pathology.  It  not  only  produces  local 
symptoms  depending  directly  upon  the  character  of  the  pathology 
present,  but,  by  its  undermining  of  the  equilibrium  of  the  nervous 
system,  can  account  for  almost  any  type  of  nervous  phenomena.  In 
fact,  there  are  few  abnormal  conditions  of  the  body  that  have 
greater  disturbing  influences  on  the  nervous  system,  especially 
when  we  consider  that  the  abnormality  is  of  the  type  of  pathology 


100  THE  GYNECOLOGY  OF  OBSTETRICS 

that  is  not  dangerous  to  life.  Moreover,  these  general  symptoms 
are  often  associated  with  only  mild,  or  even  overlooked,  local  dis- 
comfort. 

For  example,  in  the  case  of  Mrs.  S.,  aged  forty-five  years,  the 
following  history  is  characteristic.  She  is  the  mother  of  two  chil- 
dren, the  younger  being  eighteen  years  of  age,  both  born  under 

normal  conditions,  with  no 
injuries  reported.  For  three 
years  following  the  birth  of 
the  last  child  the  patient 
complained  of  symptoms,  the 
result  of  pelvic  congestion — 
backache  and  leucorrhea, 
with  increased  menstrual 
flow — but  these  ills  disap- 
peared under  local  treat- 
ment hj  the  family  physi- 
cian. Some  months  later  she 
l^egan  to  have  distressing- 
headaches,  referred  to  as 
"  sick  headaches,"  which,  on 
account  of  the  severe  nau- 
sea and  vomiting,  produced 
marked  prostration.  Being- 
incapacitated  for  two  to 
three  days  each  week,  she 
had  despaired  of  obtaining 
permanent  relief.  Thorough 
physical  examination  dis- 
closed no  abnormal  condi- 
tion outside  of  the  pelvis,  and  there  a  moderate  degree  of  perineal 
relaxation  and  cervical  congestion.  The  pelvic  condition  was  asso- 
ciated with  such  slight  local  symptoms  that  only  careful  question- 
ing brought  to  light  the  existence  of  some  bladder  irritation.  The 
degree  of  relaxation,  though  easily  demonstrable,  had  been  previ- 
ously overlooked.  In  this  case  the  correction  of  the  pelvic  pathol- 
ogy Avas  followed  by  the  prompt  disappearance  of  the  headaches, 
and  the  last  seven  years  has  proven  the  permanency  of  the  cure. 


This  illustrates  one  method  of  determining  the 
degree  of  relaxation  of  the  outlet.  The  finger  de- 
monstrates by  palpation  the  location  and  the 
degree  of  injury  to  the  pelvic  diaphragm.  In 
this  i^atient  an  Emmet  perineorrhaphy  was 
performed,  judging  by  the  character  of  the  scar. 


THP]  RELAX  Kl)  \'A(I1XA1.  OUTLET  101 

Aj»'ain,  Mrs.  B.,  a^-ed  thirty-live  years,  has  iiad  one  child,  Ijorn 
\vith  iiistniineiital  delivery.  Some  months  after  the  birth  of  this 
child,  the  patient's  eyes  be»-aii  to  give  trouble.  Frequent  change  of 
glasses  hrouglit  oiils-  tcinpoi-ary  relief.  'J'he  jx'lvis  gave  no  symp- 
toms, and  visits  to  two  piiysicians  in  the  hope  of  discovering  a  rea- 
son for  the  relative  stei-ility  resulted  in  the  assurance  that  every- 
thing was  normal.  This  i)atient  was  referred  by  an  oculist,  who 
reported  the  eyes  without 
defect  except  for  nuiscular 
irritability,  and  susi)ected  a 
pelvic  abnormality.  The  pa- 
tient comjilained  of  no  ])elvic 
symptoms,  and  felt  confident 
the  trouble  was  not  there. 
An  examination,  however,  re- 
vealed a  marked  degree  of 
perineal  relaxation,  with  a 
})rominent  cystocele,  of  which 
the  patient  acknowledged  be- 
ing conscious  w^hen  standing, 
but  considered  it  a  normal 
sequence  of  her  pregnancy. 
The  correction  of  this  pathol- 
ogy resulted  in  the  complete 
restoration  of  the  eyes. 

In  these  two  cases  we  have 
a  good  example  of  the  remote 
symptoms  of  jielvic  pathol- 
ogy ;  but  in  the  vast  majority 
of  cases  these  remote  symptoms  are  associated  with  very  definite 
local  conditions  that  should  at  once  attract  the  physician's  atten- 
tion. In  some  naturally  neurotic  women  the  nervous  manifestations 
may  take  even  a  more  severe  form  than  eye-strain  from  muscle- 
weariness  or  the  various  types  of  headache,  so  that  mental  states 
such  as  melancholia  or  hysteria  are  by  no  means  uncommon.  It  is 
not  safe,  however,  to  let  one's  enthusiasm,  which  is  a  natural  se- 
((uence  of  results  from  correct  perineal  work,  prevent  one  from 


The  patient  bcijiy  uskuil  to  bear  down,  a 
marked  rolling  out  of  the  vaginal  walls  takes 
place.  This  method  of  demonstrating  the  relax- 
ation also  conveys  an  idea  as  to  the  condition 
of  the  sagging  when  the  woman  is  standing. 


102  THE  GYNECOLOGY  OF  OBSTETRICS 

rememhermg  that,  even  though  a  relaxed  vaginal  outlet  is  present, 
there  may  l^e  other  causes  for  some  of  the  s^anptoms.  It  is  natural 
for  one  to  be  very  sanguine  of  the  results  from  correct  pelvic  plas- 
tic work,  for  there  is  no  other  field  in  surgery  involving  only 
external  structures  that  gives  as  good  and  as  uniform  results  in 
health  improvement. 

The  local  s^miptoms  are  either  the  result  of  the  accompan3dng 
congestion  or  are  due  to  the  interference  of  the  function  of  the  ad- 
jacent organs,  on  account  of  the  break  in  the  pelvic  diaphragm. 

Probably  the  most  frequent  complaint,  especially  in  the  severer 
types  of  injury,  is  the  feeling  of  lack  of  support,  or,  as  the  patient 
puts  it,  a  feeling  that  "things  are  going  to  drop."  This  is,  of 
course,  more  noticeable  when  standing  or  walking,  and  when  seated 
these  patients  usually  get  more  comfort  with  the  knees  crossed,  on 
account  of  the  support  given  by  the  thighs. 

Backache,  though  a  very  frequent  S3aiiptom,  is  by  no  means  al- 
ways present,  and  I  believe  it  is  more  common  in  cases  associated 
with  the  early  grades  of  uterine  and  ovarian  displacement.  As  the 
organs  drop  lower  in  the  pelvis,  it  is  not  unusual  to  find  no  mention 
of  backache,  even  in  some  severe  degrees  of  procidentia.  The 
backache  that  is  due  to  a  loose  sacroiliac  joint,  while  differing  in 
location  and  character,  is  so  often  found  in  women  who  have  borne 
children  that  it  is  very  often  confounded  with  the  reflex  ache  of 
pelvic  pathology.  Only  lack  of  thoroughness  in  examination,  how- 
ever, can  account  for  the  conflict. 

Postural  backache  and  the  sideache  and  backache  of  kidney 
ptosis  are  frequently  present  in  women,  but  usually  respond  to  cor- 
rect corset  support  and  heel  adjustment.  The  too.  popular  tendency 
to  lay  stress  on  the  pelvic  congestion  as  a  cause  of  reflex  backache 
should  always  be  combated  and  care  taken  to  eliminate  all  other 
possibilities  before  assigning  the  pelvic  injuries  as  the  cause,  or 
we  may  find  ourselves  and  the  patient  disappointed  by  the  per- 
sistence of  the  ache  after  the  operative  work. 

The  s^miptoms  that  are  the  result  of  the  pelvic  congestion  are 
directly  traceable  to  the  associated  pathology  in  the  cervix,  and 
these  (the  leucorrhea,  with  the  increased  or  irregular  menstrual 
flow)  have  been  considered  under  that  head. 


THE  RKI.AXKI)  \\\(JIXAL  Ol  TLH/P  103 

The  iiia,j()i-ity  of  women  witli  relaxed  va|i,iiial  outlets  sufTci-  i'l-om 
various  distui-hauccs  of  the  hladdei'  f'luictioii.  Krccjiieiitly  it  is  tlie 
iiud)ilityto  eouti'ol  the  s))hiu('t(M-  uniscle  when  the  bladder  heconies 
somewhat  distended,  necessitating;'  an  imuKMliate  evaeuation.  This 
condition  is  |)i'esent,  as  a  I'ule,  only  in  the  da\time  oi-  as  soon  as 
the  woman  arises  in  the  morning,  and  the  ability  to  retain  moi'e 
readily  the  urine  at  night  speaks  against  bladder  inflannnation, 
though  in  time  that  is  often  associated.  These  patients  will  usually 
tell  you  how  they  always  have  to  plan  to  iind  a  toilet  convenient 
after  a  drive  or  street-car  ride,  and  must  find  opportunity  for 
rather  frequent  evacuation.  This  is  often  associated  with  an  in- 
ability to  control  urine  leakage  on  excretion  or  when  coughing  or 
sneezing.  Such  are  the  bladder  symptoms  complained  of  in  the 
early  stages  of  relaxation. 

AMien  a  cystocele  has  develojjed,  the  inability  to  empty  the  blad- 
der completely  on  account  of  the  sagging  adds  a  new  type  of  symp- 
tom. Often  it  is  the  consciousness  that  the  bladder  is  not  empty, 
and  the  resulting  mental  distress  added  to  a  usually  irritable 
sphincter  increases  the  frequency  of  micturition,  especially  when 
arising  in  the  morning  or  after  physical  and  mental  overexertion. 
When  infection  is  sui^erimposed,  the  frequency  is  increased ;  burn- 
ing during  urination  and  pain  after  are  then  present.  The  rectal 
symptoms,  as  a  rule,  occur  earlier  than  those  of  the  bladder,  but, 
as  the  bladder  is  called  to  the  attention  more  through  its  frequent 
function,  the  rectal  symptoms  are  more  often  overlooked.  The  ear- 
liest indication,  as  a  rule,  is  constipation,  a  constipation  that  is 
due  to  a  lack  of  perfect  control  of  the  lower  rectum  rather  than  to 
any  change  in  the  peristaltic  waves  higher  up.  This  lack  of  expul- 
sive power  is,  of  course,  the  result  of  the  stretching  out  of  the  ven- 
tral rectal  wall  and  the  retraction  of  the  sphincter  ani,  due  to  the 
destruction  of  the  perineal  anchorage.  While  the  desire  for  evacu- 
ation is  present,  the  expulsive  powder,  is  wanting,  and  in  some  cases 
it  is  necessary  to  support  the  rectocele  in  order  to  accomplish  the 
emptying  of  the  bowels.  Interference  with  the  bowel  action  low 
dowai  soon  has  a  direct  reflex  effect  higher  up,  and  a  chronic  per- 
sistent constipation  results. 

On  account  of  the  sagging  interfering  with  the  return  circula- 


104      THE  GYNECOLOGY  OF  OBSTETRICS 

tion  from  the  rectum,  associated  with  a  more  or  less  spasmodic 
sx^hincter  mnscle,  the  formation  of  hemorrhoids,  especially  of  the 
external  tjj)e,  is  very  frequent.  The  lack  of  tone  in  the  stretched- 
out  rectal  wall,  the  pressure  above  from  the  enlarged  cervix  and 
the  often  low  uterine  body,  with  the  pressure  of  the  bowel  contents, 
produce  the  congestion.  In  fact,  the  presence  of  hemorrhoids  in 
women  who  have  had  children  is  exceedingly  suggestive  of  a  re- 
laxed vaginal  outlet  as  a  cause.  A  large  pelvic  tumor  is  often  asso- 
ciated with  hemorrhoids,  but  the  simple  retroversions  uncompli- 
cated b^^  an  injured  perineum  are  not  nearly  as  frequently  the 
cause  of  hemorrhoids  as  supposed. 

A  woman  with  a  marked  degree  of  relaxation  will  sometimes 
complain  of  the  audible  expulsion  of  air  from  the  vaginal  canal, 
though  often  imagining  that  it  comes  from  the  lower  bowel,  due  to 
poor  control  of  the  sphincter. 

The  permanent  patulous  condition  of  the  vaginal  canal  permits 
the  ready  ingress  of  air  when  the  patient  gets  into  a  position  ap- 
proaching the  knee-chest  or  Sims's  lateral  posture.  The  value  of 
these  two  positions  for  examination  purposes  depends  on  the  air 
distention  of  the  vagina.  Through  the  gravitation  of  the  abdominal 
and  pelvic  organs  toward  the  thoracic  diaphragm  by  the  patient's 
posture,  the  ballooning  out  of  the  canal  occurs,  thus  permitting  un- 
obstructed inspection.  In  order  that  this  may  be  accomplished  in 
an  uninjured  outlet,  it  is  necessary  to  retract  the  perineum  so  as  to 
permit  the  air  to  enter.  In  fact,  the  knee-chest  posture  as  a  thera- 
peutic procedure  is  of  little  value  unless  the  patient  is  directed  to 
permit  the  entrance  of  air  by  retracting  the  perineum.  With  a  re- 
laxed outlet  a  far  less  exaggerated  position  than  the  typical  knee- 
chest  or  Sims's  allows  the  air  to  enter,  and  a  change  of  posture  as 
readily  causes  its  expulsion. 


Plate  IX 

DISSECTION  OF  A  RELAXED  VAGINAL  OUTLET 

TO  SHOW  THE  RETRACTION  OF  THE 

LEVATOR- ANI  ^lUSCLE 


This  subject  had  a  relaxed  vaginal  outlet.  The  central  tendon  has 
been  cut  through  and  pulled  aside,  thus  distorting  the  superficial 
structures,  in  order  to  show  the  absence  of  the  levator-ani  muscle 
between  the  vagina  and  rectum,  the  only  tissue  intervening  be- 
tween these  canals  being  a  layer  of  fascia.  The  levator-ani  fibers 
are  shown  retracted  to  the  attachment  of  that  muscle  to  the  va- 
gina. Beneath  this  portion  of  the  muscle  a  strip  of  white  cloth  has 
been  placed,  in  order  to  show  the  size  and  relation  of  the  middle 
segment  of  the  levator  ani. 


PKKINEORRHAPHY 

F(  )li  a  cori-cct  I'c'paii-  of  the  i-claxcfl  N'a.i'-iiial  outlet  a  tliorou^h 
kiio\vl(Mli;('  of  the  normal  |)('riii(Miiii  is  essentia!,  and  with 
such  kno\vh'(lt;('  any  of  the  acK'ocatefl  repairs  can  he  ina(h' 
successt'uh  no  niattei'  wiiat  the  Form  of  (ienu(hition  or  the 
luetliod  of  suture.  Gynecological  literature  is  continually  suggest- 
ing new  varieties  of  perineal  operations;  and  yet,  when  everything 
is  c()nsi(hM-e(l,  jiractically  the  only  advance  of  recent  years  woi-th 
nuirked  notice  is  that  of  the  differentiation  and  direct  nnion  of  the 
separate  structures  to  l)e  unite(L  With  this  statement  we  record 
the  only  vital  difference  between  the  flap-splitting  operation,  the 
outgrowth  of  the  original  Tait,  which  was  exceedingly  su|)eriicial, 
and  the  j)o])ular  operation  of  today,  credited  under  the  names  of 
various  oj)erators.  All  other  variations  are  siinph'  methods  of 
suture  ai)j)lication  or  structure  separation.  The  vaiiety  of  suture 
or  the  method  of  its  application  will  always  be  a  matter  of  the  op- 
eiator's  personal  i)reference.  Again,  the  extensive  dissection,  with 
the  sepai-ation  of  tissue,  no  matter  how  accomplished,  is  contrary 
to  the  normal  anatomical  relation,  and  favors  some  complications. 
To  produce  a  correctly  functionating  perineum,  it  is  essential  to 
accomplish  not  onh^  a  union  of  the  pelvic  floor,  but  of  the  pelvic 
diaphragm  as  well. 

Wells  in  a  recent  paper  gives  the  following  steps  as  necessary 
'to  get  jierfect  results  in  au}^  perineal  repair,  and  advises  the  fla])- 
splitting  method  as  the  best  to  accomplish  the  result : 

"First,  the  miion  of  the  fibers  of  the  levator-ani  nrascle  with 
their  proper  perineal  attachment ;  second,  the  restoration  of  the 
fascial  covering  of  this  muscle ;  third,  the  union  of  the  two  layers 
of  fascia,  the  pelvic  and  perineal,  at  their  points  of  nmtual  attach- 
ment, namely,  in  the  center  of  the  perineum;  fourth,  the  restora- 
tion of  the  action  of  the  transversus-perinei  muscles,  which  have 
hitherto  drawn  upon  the  severed  fil)ers  of  the  levator-ani  nmscle  in 
a  lateral  direction,  flattening  the  caliber  of  the  vagina  and  causing 
it  to  gape." 


106      THE  GYNECOLOGY  OF  OBSTETKICS 

Theoretically,  this  advice  is  excellent.  Practically,  even  in  the 
hands  of  the  expert,  its  accomplishment  in  every  case  is  exceeding- 
ly problematic.  In  many  cases  of  dissection  in  the  anatomical  lab- 
oratory it  is  impossible  to  separate  to  one's  satisfaction  the  layers 
of  fascia  entering  into  the  construction  of  the  pelvic  diaphragm 
from  the  muscle  itself,  on  account  of  the  close  blending.  What  can- 
not be  done  under  conditions  entirely  favorable  to  its  accomplish- 
ment can  hardly  be  possible  in  the  operating-room.  Moreover,  in 
the  injured  perineum  the  distortion,  on  account  of  the  muscle  re- 
traction and  the  scar-tissue  formation,  further  complicates  the 
separation.  No  matter  what  the  distortion  or  how  great  the  muscle 
separation,  it  is  always  possible  even  without  dissection  in  all 
forms  of  denudation  to  pick  up  the  edges  of  the  levator  ani  later- 
ally at  its  middle  segment  for  direct  suture  to  the  corresponding 
portion  on  the  other  side.  The  function  of  the  vaginal  sphincters 
is  of  just  as  much  importance  as  the  transversus  perinei,  but 
probably  the  first  step,  consisting  of  "the  union  of  the  levator-ani 
muscles  with  their  proper  perineal  attachment,"  is  intended  to 
care  for  them. 

Since  the  early  days  of  gynecology  there  have  been  three  types 
of  operation,  and  upon  these  practically  all  our  multitudinous  mod- 
ern operations  are  built,  though  too  often  the  worthy  pioneer  loses 
the  credit  of  the  procedure  by  the  addition  of  unessential  varia- 
tions. 

These  three  classical  operations  which  w^e  should  still  do  well  to 
bear  in  mind  are  the  Tait,  the  Emmet,  and  the  Hegar. 

First,  we  have  Tait's  method  for  the  incomplete  tear.  The  Tait, 
however,  that  is  here  described  is  the  result  of  a  gradual  develop- 
ment of  the  originally  described  operation,  which  was  exceedingly 
superficial.  This  consists  of  a  linear  incision  carried  along  the 
mucocutaneous  border  from  a  point  a  half  inch  or  less  dorsal  to 
the  orifice  of  one  gland  of  Bartholin  to  a  corresponding  point  in 
relation  to  the  other.  This  incision  was  carried  beneath  the  mu- 
cous membrane  or  the  scar  tissue,  and  by  a  dissection  separating 
the  vaginal  mucosa  a  flap  was  formed  which  was  continued  well 
out  in  the  lateral  aspects,  exposing  a  broad  area  of  perineal  tissue 
beneath  the  imperforated  mucous  membrane.  This  flap-splitting 


PERINEOHRTIAPHY  107 

was  c'arri('(|  up  to  n  point  aboNc  the  pelvic  diap]ii-a,i;iii.  'I'lic  area  of 
perineal  structui'e  exposed  when  tlie  flap  was  elevated  was  then 
a|)|)i-oxiniat('(l  from  side  to  side.  'IMie  sutures,  if  iiisei'te(l  deeply 
eiiou,i;li  ill  the  lateral  tissues  aud  made  to  exit  in  the  median  line 
before  reinsertion  on  the  opposite  side,  produced  a  flat  approxi- 
mation of  tissue  instead  of  a  puckering-string  effect.  The  first  su- 
ture was  i)laced  dorsally  in  the  denudation,  the  remaining  sutures 
inserted  at  short  distances  apart  from  below  upward,  the  last  su- 
tui'e  passing  tln-ougli  the  under  surface  of  the  flap  in  the  depth  of 
the  wound  so  as  to  eliminate  any  dead  space  and  anchor  the  mu- 
cous membrane.  The  portion  of  the  flap  which  did  not  naturally 
recede  within  the  vagina  upon  tying  the  sutures  in  the  order  in- 
serted was  stitched  over  with  a  superficial  suture,  to  close  any 
raw  spaces. 

Practically,  the  difference  between  this  operation  and  our  pres- 
ent-day flap-splitting  is  the  difference  between  the  older  ' '  through 
and  through  "  closure  of  the  abdominal  wall  and  the  more  careful 
layer  approximation  of  the  present.  But  no  one  can  deny  the  fact 
that  the  majority  of  closures  by  the  old  method  were  successful, 
even  though  we  realize  that  the  present  method  is  more  uniformly 
satisfactory. 

For  the  complete  tear  of  the  perineum  no  scheme  of  incision  and 
denudation,  whether  the  flaps  are  left  intact  or  removed,  serves 
the  purpose  as  ingeniously  as  the  Tait.  It  differs  from  the  opera- 
tion for  the  incomplete  injury,  in  that  a  line  of  incision  is  carried 
dorsally  on  either  side  of  the  rectovaginal  cleft,  starting  at  points 
that  would  be  about  the  limits  of  the  middle  third  of  the  original 
incision  for  incomplete  repair.  These  dorsal  incisions  are  carried 
far  enough  down  to  make  the  findings  of  the  ends  of  the  external 
sphincter  ani  easily  accomplished.  If  we  bear  in  mind  that  nearly 
always  we  have  a  superficial  dimple  formed  where  the  ends  of  the 
torn  muscle  have  become  attached  to  the  superficial  structures,  and 
that  these  landmarks  are  usually  well  defined,  we  shall  have  no  dif- 
ficulty in  deciding  the  extent  of  the  incisions. 

Tait,  writing  in  1879,  describes  his  operation  for  the  complete 
injury  as  follows,  though  later  descriptions  by  other  men  give 
somewhat  different  versions: 


108      THE  GYNECOLOGY  OF  OBSTETRICS 

"  In  case  of  complete  tear  of  the  perineum,  my  method  of  oper- 
ating is  this :  I  make  two  incisions  abont  one  inch  and  a  half  long, 
just  at  the  margin  of  the  skin  and  mncons  membrane,  and  marking 
the  edges  of  the  torn  perineum.  These  will  be  more  or  less  apart, 
according  to  the  depth  of  the  tear.  They  should  be  nearly  parallel, 
but  somewhat  converging  toward  the  coccyx.  The  knife  is  carried 
right  through  the  skin  down  to  the  subjacent  tissues,  and  the  rest 
of  the  operation  is  done  by  strong,  sharp-pointed  scissors.  These 
are  introduced  just  under  the  skin  at  the  upper  end  of  each  w^ound 
and  run  under  the  mucous  membrane  (cutting  nothing  else)  about 
half  an  inch  from  each  side  inwards,  meeting  in  the  middle  line, 
and  forming  a  curve  parallel  with  the  margin  of  the  torn  septum. 
The  lower  lip  of  this  wound  is  then  seized  by  dissecting  forceps 
and  the  mucous  membrane  carefully  raised  from  the  adjacent  tis- 
sues as  far  as  the  edge  of  the  rent,  but  not  separated  at  that  edge, 
so  as  to  form  a  flap.  This  flap  is  turned  downwards  and  backwards 
into  the  rectum.  A  stout  curved  needle  armed  with  strong  Chinese 
silk  is  then  to  be  introduced  about  a  quarter  of  an  inch  from  the 
center  of  the  skin  wound  on  one  side,  and  carefulh^  carried  through 
the  tissues  of  the  septum  till  its  point  is  within  a  quarter  of  an  inch 
of  the  middle  line.  The  point  is  then  to  be  brought  out  in  front  of 
the  flap  and  passed  into  the  septum  again  at  about  another  quarter 
of  an  inch  on  the  other  side  of  the  middle  line,  and  is  then  to  be  con- 
tinued till  it  comes  out  at  a  point  corresponding  to  its  original 
insertion.  The  whole  success  depends  upon  this  stitch,  so  that  the 
utmost  care  must  be  taken  with  it.  Two  other  stitches  are  similarly 
introduced,  one  in  front  of,  and  the  other  behind,  the  first  stitch, 
and  all  three  must  be  in  front  of  the  flap. ' ' 

In  case  this  original  Tait  method  will  not  apply,  a  modification 
may  be  readily  devised,  which  will  give  a  dorsal  flap  that  may  be 
turned  into  the  rectum  as  its  ventral  wall,  thus  protecting  the  peri- 
neum from  contamination. 

In  an  extensive  injury,  where  the  defect  in  the  ventral  rectal  wall 
is  high,  there  is  no  mucocutaneous  line  as  a  guide  for  the  first  in- 
cision, and  the  location  of  that  incision  is  a  matter  of  judgment  for 
each  individual  case.  The  flap,  which  is  dissected  upward  and 
turned  into  the  vagina  as  described,  having  to  cover  a  much  greater 
area  in  length,  must  consequently  be  of  larger  proportional  size, 
though  in  the  majority  of  cases  the  vaginal  flap  may  be  eliminated 
entirely,  as  in  the  Tlegar  denudation.  The  dorsal  flap  need  be  made 


PERINEORRIIAIMIV  109 

only  of  suHicicnt  l('ii,i;tli  to  reach  just  Ix'yoiid  tlic  point  iliat  will  be- 
coiiic  the  \-eiiti-al  e(l,i;('  of  the  anus  when  the  sphiiieter  niusele  is 
sutured  o\'er  the  downwardly  retraete(l  ineiu])i-ane.  This  dorsal 
ilap,  as  a  rule,  nee(ls  hut  sli,i;lit  dissection  al'ter  the  scar  tissue  has 
heeii  cut  tlirou,i;h,  tor  it  will  easil>-  retfact  (lowiiwai-d.  With  the  rec- 
tal Hap  i)ulle(l  dowu  and  the  va,<;inal  i-eti-acted  u|)wai-d,  the  resiilt- 
iui;-  denuded  area  is  ck)se(l 
from  side  to  side  in  the  same 
manner  as  in  the  incomplete 
operation,  the  sphinctei-  ani 
having-  been  first  repaired 
by  direct  sutnre.  Such  an 
approximation  adds  to  the 
length  of  the  vaginal  canal 
a  distance  equal  to  one-half 
the  width  of  the  denuded 
area,  and  the  portions  of  the 
two  flaps  that  are  not  used 
in  forming  the  covering  of 
this  increased  length  of  ca- 
nal may  he  removed  and  the 
edges  sutured.  But,  general- 
ly, the  redundancy  is  slight, 
and  the  normal  shrinkage 
will  take  care  of  the  excess. 

The  dorsal  incision  of  both 
the  Hegar  and  Ennnet  in- 
complete operations  follows 
the  lines  of  the  Tait  along- 
the  mucocutaneous  border. 
P\)r  the  complete  injury,  lat- 
eral incisions  toward  the  anus  are  added  as  the  method  of  ohtain- 
ing  tissue  for  the  ventral  rectal  wall  and  reaching  the  retracted 
sphincter  ends.  Thus  in  the  dorsal  aspect  of  the  denuded  area  they 
do  not  differ  either  in  the  resulting  line  of  union  or  suture  appli- 
cation. 

The  completed  Tait  operation  is  represented  by  a  linear  line  of 


This  patient  serves  as  another  illustration  of 
poor  diaphragm  support  following  an  imperfect 
perineorrhaphy.  To  casual  observation  the  re- 
sults seem  good,  though  there  is  a  small  point 
of  the  rectocele  visible.  The  distance  from  the 
posterior  commissure  to  the  anus  is  about  nor- 
mal, the  contour  of  the  parts  being  good.  This 
is  a  result  of  a  good  approximation  of  the  pelvic- 
floor  structures. 


no      THE  GYNECOLOGY  OF  OBSTETRICS 

union  from  the  anus  to  the  vaginal  "  posterior  commissure  "  in  the 
complete  tear,  Avith  about  the  ventral  half  of  that  length  in  the 
incomplete  tear,  each  line  being  approximated  by  transverse  inter- 
rupted sutures.  The  other  operations  differ  only  in  the  internal 
vaginal  aspect. 

In  the  Hegar  operation  a  point  is  selected  on  either  side  of  the 
vaginal  orifice  sufficiently  below  the  openings  of  the  glands  of  Bar- 
tholin and  in  the  line  of  tlu^ 
' '  carunculae   myrtif ornies  ' ' 
so  that  when  the  points  are 
approximated  a  vaginal  ca- 
nal entrance  of  normal  di- 
mensions is  formed;  for,  on 
suture,  these  points  come  to- 
gether  in  the  new   "poste- 
rior  commissure."  A  third 
point  is  chosen  on  the  dorsal 
vaginal  wall  in  the  median 
line,  the  height  of  this  point 
depending  on  the  amount  of 
redundant    vaginal    mucous 
membrane  and  the  extent  of 
the  rectocele,  but  it  should 
be  high  enough  to  allow  easy 
access    to    the    pelvic    dia- 
phragm. These  three  points 
caught   in   forceps   and   re- 
tracted   give    a    triangular 
area  which  is  then  outlined 
by  incisions  and  the  enclosed 
mucous  membrane  denuded. 
If  the  lateral  lines  of  this  triangle  are  made  to  diverge  some- 
what at  the  depths  of  the  sulci  which  mark  the  line  of  cleavage  in 
the  injured  pelvic  diaphragm,  it  will  be  found  easier  to  pick  up  the 
retracted  muscle.  Better  support  will  be  given  to  the  ventral  va- 
ginal wall  by  the  slightly  greater  area  of  denudation,  but  this 
slight  modification  simply  helps  in  the  approximation  of  individual 


The  labia  separated  while  the  patient  bears 
down  shows  the  marked  relaxation  above  the 
floor.  The  character  of  the  scar  would  indicate 
either  an  Emmet  or  Hegar  denudation.  The 
tubercle  of  the  vagina  is  somewhat  prominent, 
but  there  is  no  evidence  of  cystocele  upon  fur- 
ther examination. 


PERIXKOIMMIAIMIV  111 

striH'tui'cs,  ;iii(l  <'aii  liardix'  he  ('()iisi(l('rtMl  as  cliaii^iiiu-  llic  cliaracter 
of  the  opcralioii. 

The  original  I  l(',t;ar  ope  rat  ion  a|)|)i-()\iiiiat(Ml  this  area  of  dciiiKla- 
tioii  I'loiii  side  to  side  with  (h'cply  iiiscrtccl  iiit('ri-ii|)t(Ml  sutui-('S. 
The  more  iiii|)oftaiit  sutiifcs  al\va_\s  ('xit('(l  in  the  median  line  Ix'- 


The  points  uf  forceps  api>lieatiou  indicate  the  angles 
of  the  Hegar  denndation  of  the  degree  that  is  neces- 
sary   in    this    case.    The    orifices    of   the    glands    of 
Bartholin  are  plainly  evident. 

fore  reinsertion  on  the  o^iposite  side,  in  order  to  obtain  a  fiat  ap- 
proximation, and  also  to  prevent  injury  to  the  rectum. 

The  main  advantages  advocated  for  the  Tait  operation  over  the 
Hegar  were,  first,  that  in  the  Tait  no  injury  existed  within  the 
vagina — a  point  of  importance  in  the  early-day  surgery,  but  hardly 
of  consequence  with  our  modern  asepsis;  second,  that  the  Tait 
sacrificed  no  tissue,  and  thus  was  more  applicable  to  cases  of  ex- 
tensive injury  in  which  scar-tissue  contractions  had  formed. 


112      THE  GYNECOLOGY  OF  OBSTETRICS 

Emmet  plamied  his  operation  to  take  better  care  of  the  lateral 
tear  within  the  vagina  which  naturally  involved  the  pelvic  dia- 
phragm. He  probably  figured  that  the  highest  point  of  the  rectocele 
had  primarily  its  normal  attachment  at  the  external  orifice  of  the 
vagina,  but  on  account  of  the  injury  had  retracted  upward,  and  his 
operation  was  devised  so  as  to  bring  this  point  into  apposition  with 
the  two  lateral  external  angles  of  the  denudation. 

The  area  of  denudation  has  been  likened  to  an  inverted  "  W," 
though  also  called  the  "butterfly"  denudation.  The  outlines  are 
best  defined  by  taking  five  points  of  location :  one  on  each  side  ex- 
ternally, corresponding  to  the  lateral  points  in  both  the  other 
types  of  operation ;  one  on  the  crest  of  the  rectocele  in  the  median 
line,  low  enough  to  permit  of  retraction  downward  to  the  first 
XDoints;  and  one  on  either  side  of  the  rectocele  in  the  sulci,  high 
enough  to  be  above  the  injur}^  of  the  diaphragm.  These  five  points 
caught  up  with  forceps  and  put  on  tension,  and  the  lines  of  in- 
cision carried  from  one  to  the  other,  give  a  "W '-shaped  area 
with  the  angles  inside  the  vagina  and  the  mucocutaneous  line  join- 
ing the  main  arms. 

Emmet  advised  the  removal  of  the  mucous  membrane  in  narrow 
strips  by  means  of  scissors,  thereby  conserving  the  fascia  layer. 
This  raw  area  is  united  by  closing  each  angle  as  far  as  the  recto- 
cele tip  with  interrupted  sutures,  the  remaining  lozenge-shaped 
area  being  united  from  side  to  side  in  the  same  manner  as  in  the 
other  operations,  Avith  the  exception  of  what  Avas  called  the 
"  crown"  suture.  The  latter  Avas  inserted  so  as  to  give  as  broad 
an  approximation  as  possible  of  the  structures  beneath  the  recto- 
cele tip.  In  reality,  upon  the  right  application  of  this  suture  de- 
pended the  correctness  of  the  operation,  and  probably  many  critics 
failed  in  their  results  on  account  of  misunderstanding  this  step. 
The  suture  should  be  introduced  at  the  point  of  the  lateral  forceps, 
inserted  parallel  to  the  direction  of  the  A^aginal  canal,  exiting  at  the 
end  of  the  lateral  line  of  sutures  already  inserted,  then  brought 
across  under  the  puUed-up  rectocele  tip,  and  from  there  applied  to 
the  opposite  side  in  the  same  manner.  This  suture,  Avhen  tied,  pulls 
in  not  only  all  the  structures  blending  into  the  central  tendon,  but 
also,  if  properly  applied,  the  retracted  levator-ani  segment.  Thus 


Plate  X 

THE  MAIN  MUSCLE  STRUCTURES 
OF  THE  PELVIC  FLOOR 


Here  an  attempt  is  made  to  emphasize  the  main 
muscle  structures  of  the  pelvic  floor.  The  sepa- 
ration of  the  superficial  and  deep  muscles  was 
not  attempted,  and  probably  some  of  the  super- 
ficial fibers  have  been  removed  with  the  inter- 
vening fascia  layers.  The  surgical  interest  being 
the  purpose  in  mind,  I  have  attempted  to  define 
and  emphasize  the  main  muscle  structures  in  their 
relation  to  the  central  tendon  and  to  one  another. 


PERINEORRHAPI I V  113 

is  ToriiKMl  the  "  postci-ior  coiiimissui-c,'"  and  the  rcinaiiiini;'  area 
united  hy  dccj)  sutures  becomes  the  luediandine  skin  apixjsition. 
The  rcsultiu.L;-  line  of*  union  eoi'i-espouds  to  the  line  of  the  "  Y  "- 
sluijx'd  injury  |)r('\i()usly  (h'scrilx'd. 

The  operations  of  the  present  <h\y  einph)y  in  evei-y  case  one  of 
these  chissical  denudations,  with  perliaps  a  sli.i>lit  niodihcation  to 
suit  tlie  individual  surg-eon  or  accommodate  the  character  of  the 
])articular  injury.  The  difference,  as  lias  been  said,  between  the  old 
and  the  new  is  that  the  sur,<;'eon  now  attempts  to  separate  and  de- 
line  tlu'  vai-ious  structures  and  unite  them  individually,  and  this  he 
does  by  some  ])ref erred  method  of  suture,  each  method  of  suture 
or  slig-ht  modification  of  denudation  going  by  a  different  name.  A 
detailed  consideration  of  these  multitudinous  methods  is  of  no 
value,  for  if  the  principles  involved  are  understood  each  operator 
will  consider  the  individual  case  and  apply  thereto  the  methods 
best  suited.  A  surgeon  adopting  one  type  of  operation,  and  be- 
coming expert  therewith,  can  readily  modify  that  type  to  fit  the 
individual  variations. 

While  a  detailed  consideration  of  the  various  modern  operations 
will  not  be  imdertaken,  there  are  phases  of  some  methods  which 
are  worthy  of  consideration  and  study. 

The  operation  Avhich  seems  to  find  most  favor  at  the  present  time 
is  one  probably  first  advocated,  at  least  in  some  of  its  aspects,  by 
Hall,  of  Cleveland,  though  Watkins,  of  Chicago,  published  a  meth- 
od almost  identical  about  the  same  time.  Their  incision  follows  the 
nuicocutaneous  border  around  the  dorsal  edge  of  the  vaginal  canal. 
The  dorsal  vaginal  nmcous  membrane  is  then  dissected  up,  which 
often  can  most  easily  be  done  by  means  of  scissors  inserted  under 
the  membrane,  then  opened  and  withdraAvn.  When  enough  room  is 
ol^tained,  separation  laterally  is  continued  by  the  gauze-covered 
finger  until  a  sufficient  area  for  reaching  the  levator  ani  has  been 
exposed.  So  far  this  differs  in  no  way  from  the  Tait  incomplete 
perineorrhaphy.  At  this  stage  Morris,  of  New  York,  inserts  the 
closed  scissors  in  the  plane  of  the  pelvic  diaphragm  in  an  outward 
and  ventral  direction  for  a  distance  of  about  one  inch ;  the  blades 
then  opened  and  withdrawn  leave  a  space  through  which  the  leva- 
tor ani  can  easily  l)e  reached.  Hall  picks  up  the  levator  without  so 


114  THE  GYNECOLOGY  OF  OBSTETRICS 

mucli  tissue  separation  and  dissects  out  carefully  the  muscle  edges. 
The  edges  of  the  muscle  are  then  picked  up  and  united  beneath  the 
flap  hj  several  interrupted  absorbable  sutures.  The  first  suture 
placed  and  tied  is  pulled  downward,  thus  permitting  a  higher  one 
to  be  readily  applied.  This  draws  in  the  tissues  of  the  diaphragm 
toward  the  median  line,  and  thus  lifts  up  the  dorsal  vaginal  wall 
so  that  it  tends  to  close  the  vaginal  canal.  The  pelvic-floor  struc- 
tures are  then  approximated  beneath  the  diaphragm,  and  the  skin 
incision  is  closed  by  some  operators  in  the  same  direction  as  the 
incision  was  made.  This  method  repairs  the  injuries  to  both  the 
floor  and  the  diaphragm,  but  does  away  with  none  of  the  mucous 
membrane,  so  that,  for  cases  with  much  scar  tissue  and  no  redun- 
dancy of  mucous  membrane,  it  is  ideal. 

It  is  claimed  by  some  of  the  advocates  of  this  operation  that  the 
stab  of  the  scissors  goes  under  the  fascia  layer  covering  the  levator 
ani,  and  thus  permits  the  picking  up  of  the  muscle,  but  in  the  ma- 
jorit}^  of  cases  the  anal  fascia  is  intimately  interwoven  with  the 
muscle,  and  the  separation  is  impossible.  On  this  account  the  theo- 
retical union  of  the  muscle,  followed  by  the  reinforcement  by  the 
anal-fascia  approximation,  as  suggested  by  Wells,  is  practically 
impossible  of  accomplishment.  In  reality,  the  scissors  simply  sepa- 
rates the  normal  attachment  of  the  levator  ani  with  its  enclosing 
fasciae  from  the  structures  of  the  pelvic  floor ;  it  enters  the  lateral 
structures  between  the  deep  layer  of  the  triangular  ligament  and 
the  anal  fascia.  Whether  such  separation  is  of  value  is  question- 
able, for  it  is  not  essential.  By  such  separation  we  disturb  not  only 
the  normal  relations,  but  we  interfere  with  the  blood  supply,  es- 
pecially the  venous  flow,  which  here,  on  account  of  the  relaxed  va- 
ginal outlet,  is  often  varicose,  so  that  bleeding  of  a  character  hard 
to  control  and  dangerous  to  the  success  of  the  operation  may  be 
encountered. 

The  portions  of  the  levator  ani  thus  united  are  called  by  most 
writers  the  pubococcygeus  fibers.  Anatomically,  this  designation 
refers  to  that  portion  of  the  muscle  running  from  the  bony  attach- 
ment on  the  pubes  to  the  tip  and  sides  of  the  coccyx.  If  it  is  true 
that  these  are  the  fibers  united,  it  naturally  justifies  the  conclusion 
that  they  are  pulled  out  of  their  normal  course  and  made  to  ap- 


Plate  XI 

BLENDING  OF  THE  LEVATOR-ANI  MUSCLE 

AVITLI  TLIE  MUSCLES  OF  THE  FLOOR 

AT  THE  CENTRAL  TENDON 


AMft 


The  purpose  of  this  iUustration  is  to  show  how 
the  levator-ani  muscle  blends  with  the  super- 
ficial muscles.  No  attempt  was  made  to  sepa- 
rate the  superficial  muscles  of  the  floor  from 
the  deep  muscles,  but  the  fascia  layers  Avere 
removed  between  the  individual  muscle  groups. 
These  muscle  groups,  indicated  by  initials,  are 
pulled  aside,  so  as  to  emphasize  the  close 
blending  of  the  attachments  at  the  central- 
tendon  area  and  the  side  of  the  vagina.  This 
blending  I  wish  to  emphasize,  since  it  shows 
that  the  scissors  puncture  in  perineorrhaphy  is 
not  a  necessary  procedure  in  picking  up  the 
levator  ani  if  the  tear  has  extended  through 
the  central  tendon.  In  this  subject  the  muscles 
are  well  developed. 


I'KinXKOIiiniAIMIV  115 

pi'oxiiiiatc  xciitral  to  llic  rcctiiiii  as  a  support  to  the  \'a,L:,iiia.  Such 
l)eiiii;'  so,  it  semis  i-casouablc  to  su))])os('  that  the  iioi-inal  working- 
of  tlu'  iiuiscle  as  an  elevator  of  the  rectum  would  he  interfered 
witli  and  tlie  tendenc>-  to  separation  where  unite(l  wouhl  he  ^Teat. 
If  we  were  (h'alin.i;'  with  the  uiah'  peK'ic  diaphra.uin,  such  an  oj)er- 
ation  wouhl  in  reality  unite  the  lihers  noruudlx'  passini;-  to  tlie  outei* 


A  itlaxatioii  of  the  vaginal  outlet  of  moderate  de- 
gree. In  this  case  also  the  central  tendon  is  only 
slightly  injured.  Abdominal  Tvork  had  been  done  in 
this  patient,  but  the  external  plastic  work  had  not 
been  recognized  as  essential. 

side  of  the  rectum,  for,  if  we  can  accept  the  anatomical  descrip- 
tions as  correct,  there  are  no  fibers  rimning  in  front  of  the  rectum. 
Pierson  describes  the  male  levator  ani  thus : 

"From  this  long  line  of  origin  the  fillers  converge  downward 
and  medially  to  be  inserted  into  the  sides  and  tip  of  the  coccyx, 
into  a  tendinous  raphe  extending  in  the  median  line  between  the 
tip  of  the  coccyx  and  the  anus  and  into  the  sides  of  tlie  lower  part 


116  THE  GYNECOLOGY  OF  OBSTETRICS 

of  the  rectum.  The  fibers  from  the  most  anterior  portion  of  the 
origin  pass  ahnost  directly  backward  and  downward  to  reach  the 
sides  of  the  rectmn. " 

Consequent!}^,  in  the  male  perineum  the  muscle  edges  exposed  in 
such  a  method  of  dissection  as  that  used  in  the  repair  of  the  female 
outlet  would  naturally  be  the  pubococcj^geus  fibers,  since  the  muscle 
is  seldom  in  separate  segments.  In  the  female,  however,  as  we  have 
shown,  there  is  a  more  or  less  distinct  separation  of  the  levator-ani 
muscle  into  segments.  The  segment  running  behind  the  rectum  has 
no  fibers  from  the  pubic  bone,  as  all  these  fibers  have  their  origin 
in  the  dorsal  portion  of  the  "  white  line."  The  fibers  arising  from 
the  pubic  bone  and  the  ventral  segment  of  the  ' '  white  line ' '  run 
to  the  sides  of  the  vagina  and  urethra,  and  between  the  vagina  and 
rectum  in  usually  two  distinctly  separated  segments.  Thus,  it  is  the 
middle  segments,  or  what  corresponds  to  the  middle  segments  if 
there  is  no  distinct  division,  that  are  picked  up  and  united  beneath 
the  vagina.  In  no  way,  then,  is  the  rectal  sling  interfered  with,  as 
can  readily  be  demonstrated  by  vaginal  and  rectal  palpation. 

The  scissors  puncture  is  not  only  unnecessary,  but,  as  I  have 
stated,  may  be  injurious,  for  when  the  muscle  is  simply  picked  up 
with  a  vulsellum  it  comes  readily  into  the  median  line  and  its  rela- 
tions to  the  pelvic  floor  and  central  tendon  are  not  disturbed.  This 
gives,  I  believe,  a  better  and  more  normal  support. 

For  a  relaxed  vaginal  outlet  in  a  case  with  only  a  moderate  re- 
dundancy of  the  vaginal  mucous  membrane,  the  flap  operations  are 
without  doubt  the  methods  of  choice.  There  is  always  a  consider- 
able gain  in  tone  of  the  vaginal  w^alls  following  a  correct  perineal 
operation,  and  where  the  relaxation  is  not  extensive  this  improve- 
ment takes  care  of  the  excess.  However,  the  majority  of  patients 
with  an  injured  perineum,  especially  where  the  condition  has  been 
of  long  standing,  have  not  only  excessive  relaxation  of  the  dorsal 
vaginal  walls,  but  also  of  the  ventral,  and  this  involves  as  well  the 
fascia  layers  beneath  the  muscle  tissue.  There  is  no  way  of  correct- 
ing either  the  mucous  membrane  or  the  fascia  relaxation  without 
eliminating  some  of  the  mucous  membrane  and  building  up  the 
fascia  layers  beneath.  This  can  be  best  accomplished  by  a  denuda- 
tion of  the  Hegar  type,  which  is  not  limited  in  its  area,  as  is  the 


Platk  XII 

PORTION  OF  THE  LP]VATOR-AXI  .Ml'SCLE 

BP7rWEP]N  THE  VAdlXA  AND 

THE  RECTUM 


The  central  tendon  is  cut  through  and  sewed  to  the 
side,  in  order  to  expose  the  levator  ani  and  its 
fascia  layer.  The  fascia  layer  has  been  partially 
separated  and  shows  (uncolored)  between  the  sling 
of  the  levator  ani  and  the  central  tendon  structures. 
A  piece  of  cloth  is  placed  beneath  the  portion  of  the 
levator  ani  that  runs  between  the  vagina  and  rec- 
tum. The  blending  of  the  deep  ventral  muscles  of 
the  floor  with  this  segment  of  the  levator  ani  is 
evident  in  this  dissection. 


Plate  XI I  L 


snows  TIIK  INDIVIDUAL  :\III)I)LK  SK(i.MHXT 
OF  THE  LEVATOR-AXl    .MI'SCLK 


The  structures  superficial  to  the  levator-ani  mus- 
cle are  severed  at  their  attachments  to  the  pubic 
arch  on  the  subject 's  right  and  pulled  over  to 
the  left.  This  shows  the  middle  segment  of  the 
levator-ani  muscle  as  it  passes  cephalad  to  the 
right  crus  from  its  ' '  white  line  ' '  origin  to  its 
insertion  into  the  side  of  the  vagina  and  between 
the  vagina  and  rectum.  A  piece  of  white  cloth 
lies  under  its  dorsal  edge,  in  order  to  show  that 
it  is  not  only  distinct,  but  that  it  overlaps  the 
ventral  portion  of  the  dorsal  segment.  The  struc- 
tures running  into  the  central  tendon  are  pulled 
aside  over  the  cloth,  so  that  the  blending  of  the 
dorsal  segment  of  the  levator-ani  muscle  with  the 
central  perineal  tendon  is  shown  at  the  line  of 
demarcation  between  the  muscle  and  tendon  struc- 
tures (colored  red)  and  the  uncolored  levator  ani. 


]n^:RIXK()KRIIAIMIV  117 

Fjiiiiict,  !)>•  tlic  tip  of  the  rcctocclc.  W'liilctlic  Pjiiiiict  i-cpfoduccstlK' 
injury  as  it  pi^iiiiarilx-  cxistc*!  and  eliminates  the  scar-tissue  foi-nia- 
tion  wliieli  formed  (jver  the  torn  areas,  it  <;ives  no  oppoi'tunity  to 
coi'iect  the  exeessive  stretcliini;-  of  tlie  vaginal  fasciae  that  lias 
taken  place  with  the  i-ectocele  ronnation.  It  is  important,  I  believe, 
to  take  cognizance  of  the  fascia  layers  between  the  vagina  and  rec- 
tum above  the  pelvic  diaphragm,  even  to  the  cervix  if  necessary, 
for  by  doing  so  we  aid  the  function  of  the  rectum  through  the  re- 
turn to  usefulness  of  its  nmscle,  which  has  often  Ix'come  more  or 
less  atropliic  tlirough  sti-etching.  The  reefing,  as  it  were,  of  this 
fascia  gives  tlie  stretched-out  nmscle  fibers  of  the  rectum  new 
points  of  attachment,  and  thus  an  opportunity  to  gain  renewed 
activity.  Not  only  is  the  support  of  value  to  the  rectum,  but  also,  by 
taking  off  some  of  the  strain  from  the  ventral  colporrhaphy,  is  of 
direct  value  to  the  cystocele  repair.  In  some  cases  of  excessive  re- 
dundancy, even  where  an  excellent  perineal  support  has  been  built 
l)y  a  flap  operation,  one  finds  the  vaginal  Avails  crowding  downw^ard 
and  favoring  a  pouching  of  the  rectum  and  bladder  between  the 
cervix  and  the  pelvic  diaphragm. 

The  main  objection  of  many  operators  to  the  triangular  denuda- 
tion is  the  belief  that  the  dorsal  wall  of  the  vaginal  canal  is  con- 
siderably shortened,  and  a  tendency  to  pull  down  the  cervix  and 
favor  retroversion  results.  In  reality,  the  length  of  the  dorsal  wall 
is  increased  to  a  marked  degree.  As  the  tissues  are  brought  in 
from  side  to  side,  the  apex  of  the  denuded  area  recedes  farther 
within  the  canal,  and  careful  measurement  will  show  half  an  inch 
or  more  of  lengthening  with  improved  lateral  support  along  the 
whole  vagina.  It  is  essential,  however,  to  pick  up  the  fascia  layers 
laterally  well  underneath  the  edge  of  the  denudation,  and  not 
simply  to  unite  the  nmcous  membrane  alone,  if  we  expect  to  get 
proper  support  of  the  rectal  canal. 

The  claim  for  great  advantage  through  having  no  incision  line 
within  the  vagina,  on  account  of  its  supposed  aid  to  the  better  heal- 
ing and  the  greater  freedom  from  infection,  has  no  basis.  As  the 
vaginal  region  is  relatively  resistant  to  infection,  the  ordinary 
aseptic  care  should  eliminate  the  danger  of  outside  contamination. 
In  no  case  should  a  repair  be  undertaken  if  there  is  any  danger  of 


118      THE  GYNECOLOGY  OF  OBSTETRICS 

infection  by  discharges  from  above.  Outside  of  the  conservation  of 
tissue,  the  flap  operation  has  no  advantage  over  those  in  which  the 
mucous  membrane  is  removed. 

The  manner  of  suturing  these  various  types  of  operation  will 

alwaA'S  largely  depend  upon 
the  operator's  preference.  No 
matter  whether  an  absorb- 
able buried  suture  is  used  to 
approximate  the  various  ele- 
ments, or  a  non-absorbable 
one  applied  from  the  surface 
as  a  simple  stitch  or  a  figure- 
of-eight,  the  results  will  be 
satisfactory  in  the  hands  of 
the  surgeon  who  understands 
the  principles  involved.  The 
general  preference  is  for  the 
buried  interrupted  absorbable 
sutures  to  approximate  the 
pelvic  diaphragm  and  then 
the  floor,  and  the  whole  re- 
inforced externally  by  a  few 
silkworm-gut  sutures  for  lat- 
eral support. 

For  the  average  repair,  my 
preference  is  for  the  Hegar 
denudation,  the  upper  angle 
above  the  diaphragm  being- 
closed  by  interrupted  catgut 
sutures  uniting  both  mucous 
membrane  and  fascia.  When  the  upper  level  of  the  levator  ani  is 
reached,  continuous  mattress  sutures  of  silkworm  gut  are  used  to 
approximate  first  the  levator-ani  fibers  and  fascia,  which  structures 
are  pulled  well  up  in  the  field  by  vulsellum  forceps ;  then  the  su- 
tures are  continued  on  through  the  central  tendon.  The  first  suture 
is  placed  in  the  depth  of  the  denudation;  it  is  carried  from  side  to 
side  at  about  the  distance  of  a  quarter  of  an  inch  from  the  median 


The  completed  operation  after  a  modified  meth- 
od of  Somers.  The  four  silkworm-gut  sutures 
used  in  the  approximation  are  clamped  together 
with  a  shot.  The  ends  distal  to  the  shot  will  be 
removed.  Note  especially  the  absence  of  any 
constriction  of  tissue. 


PKIMNKOinniAlMIV  119 

line.  ;iii(l  as  it  proceeds  the  tissues  are  caferiill)-  |»i('ke(l  ii|)  so  as  to 
lea\-e  IK)  relraele<l  si  met  II  res.  When  drawn  taut  the  suture  ap- 
pi-oxiuiates  the  sui'faees  of  Ihe  opposiiii;-  areas  traversed  hy  tlio 
stitch.  The  second  is  phiced  in  the  same  \va\-  Just  ahox'e  and  takes 
ill  more  of  the  luusch'  tissue.  These  with  the  third  suture,  still  more 
siipei  licial,  aLso  i)assiiii!,' thi'ou,i;ii  tlie  diaphra.niii  and  ceiitral-teiidoii 
structures,  l)iuld  \^^  a  dcej),  lirm  i)eriiieal  l)od>-.  The  foui-tli  suture, 
\\holl\-  suluuucous  and  sulx'uticular,  closes  the  supei-ficial  fascia 
with  the  mucous  lueinhrane  of  the  vat^'iiia  as  well  as  tlie  superficial 
portion  of  the  central  tendon  and  the  skin.  These  sutures  are  not 
tied,  for  they  remain  in  place  l)y  the  friction  of  the  tissues.  The 
h)n,U'  ends  within  the  vagina  are  gathered  togetlier  in  a  ])erf orated 
shot  and  the  shot  clamped  some  distance  away  from  the  nmcous 
membrane.  The  same  is  done  with  the  external  ends,  and  the  su- 
tures are  cut  close  to  prevent  irritation  of  the  tissues  by  the  suture 
ends.  Both  shot  are  left  sutficiently  far  from  the  tissue  line  so  as 
not  to  be  buried  if  swelling  occurs. 

The  number  of  sutures  will,  of  course,  depend  on  the  size  of  the 
denuded  area.  The  main  advantage  of  the  continuous  suture  is  that 
in  case  swelling  of  the  perineum  takes  place  there  is  no  tendency 
for  the  stitch  to  cut  into  the  softened  sw^ollen  tissue,  for  the  long 
untied,  smooth  silkworm  gut  will  accommodate  the  increased  bulk. 
AVhen  the  swelling  subsides,  the  tissues  retract  along  the  sutures 
or  can  readily  be  pushed  back.  If,  again,  by  any  possibility  infec- 
tion occurs,  as  it  occasionally  will,  the  sutures  act  as  excellent 
drains,  and  do  not  have  to  be  removed  until  the  process  subsides. 
In  fact,  the  continuous  silkworm-gut  suture  may  l)e  the  factor  that 
will  mean  a  good  result,  where  with  absorbable,  or  even  non-absorb- 
able,  interrujited  sutures  a  failure  is  inevitable.  The  presence  of 
the  shot  and  the  length  of  the  suture  aid  as  well  toward  an  easy 
removal. 

The  silkworm-gut  sutures  are  left  in  place  ten  days;  the  inner 
ends  are  then  cut  close  to  the  nmcous  membrane  and  drawn 
through  one  h\  one,  tlie  ujiper  and  the  lower  ones  usually  coming 
easily,  but  the  two  running  through  the  muscle  structure  are  often 
ludd  by  the  voluntary  contraction  of  the  patient  when  tension  is 
exerted.  There  is  no  need,  however,  of  their  innnediate  removal,  for 


120      THE  GYNECOLOGY  OF  OBSTETRICS 

as  the  patient  is  permitted  to  sit  up  the  gut  works  loose  and  can 
be  readily  withdrawn  in  a  few  days. 

If  by  any  chance  the  suture  has  been  locked  upon  itself  during 
the  insertion,  the  removal  becomes  impossible  until  the  tissue 
grasped  is  cut  through,  which  usually  occurs  after  a  little  longer 
time  than  the  ten-day  period.  Care,  however,  when  the  repair  work 
is  done,  will  readily  prevent  such  an  accident,  for  by  pulling  on  the 
suture  it  is  eas}^  to  see  just  how  much  tissue  has  been  picked  up  in 
the  preceding  stitch  on  that  side,  thus  avoiding  the  suture  material 
in  the  next  bite  of  tissue  and  the  locking  of  the  stitch. 

The  credit  for  this  method  of  continuous  mattress  suture  of  non- 
absorbable material  is  due  to  Dr.  George  B.  Somers,  of  San  Fran- 
cisco, who  began  its  use  prior  to  1901.  Since  then  several  other  op- 
erators have  advocated  a  continuous  mattress  suture  not  differing 
very  widely  from  Somers 's  method. 


CYSTOCELE 

THE  rcctocclc  is  always  cai'ccl  foi-  in  tlic  i-cpair  of  tlio  ])eri- 
iieuiii,  and  does  not  liavo  to  l)e  considered  as  an  entity.  The 
same  is  j)ra('tically  true  of  that  complication  sometimes 
found  with  tlie  injured  perineum,  the  rectovaginal  fistula. 
Occasionally,  a  fistula  of  this  kind  conies  from  a  ])us-for)iiiii.i;'  ])i-oc- 
ess  openiiii;'  into  the  vai>,ina,  but  this  is  not  connnon.  Tlic  majority 
of  sncli  oi)enings  exist  as  the  result  of  an  im))roj)er  healing  of  a 
complete  injury  at  childbirth.  A  rectovaginal  fistula  has  a  greater 
power  to  heal  spontaneously  than  has  the  vesicovaginal,  on  ac- 
comit  of  the  character  of  the  rectal  contents ;  but,  on  the  other  hand, 
if  extensive,  it  does  not  so  well  respond  to  operative  repair.  The 
majority  of  rectal  fistulae  are  situated  low  down  and  usually  just 
above  the  sphincter,  so  that  the  ordinary  perineorrhaphy  denuda- 
tion covers  the  tract.  A  careful  dissection  of  the  sinus  to  the  rectal 
wall,  with  its  ligation  or  possible  inversion,  and  a  careful  perineal 
a])i)roxiniation  surmounting  take  care  of  the  condition,  and  no 
further  special  operative  plan  is  necessary. 

When  a  fistula  is  situated  high  in  the  vagina,  but  too  high  for 
the  carrying  up  of  the  perineorrhaphy  incision,  it  is  necessary 
to  dissect  out  the  tract  from  the  vaginal  wall,  separating  freely 
tlie  vagina  from  the  rectum,  and  then  treating  the  sinus  as  a  hernia 
sac,  by  ligation,  avoiding  the  inclusion  of  the  rectal  mucosa.  One 
ingenious  operator  suggests  closing  the  edges  of  the  dissected-out 
fistulous  tract  by  a  purse-string  suture,  the  ends  of  which  are  then 
passed  out  through  the  s]^hincter  by  attaching  to  a  curved  forceps 
inserted  from  below,  thus  inverting  the  opening  into  the  rectum. 
The  reinforcing  of  the  rectal  muscularis  and  fascia,  and  above  that 
the  vaginal  structure,  practically  assures  a  successful  outcome. 

The  consideration  of  cystocele,  both  its  causation  and  correction, 
is  not  a  simple  matter.  As  has  been  already  shown  in  preceding 
chapters,  a  cystocele  is  only  a  small  part  of  a  general  abnormality, 
and  consequently  can  oidy  l)e  considered  primarily  from  that  view- 


122      THE  GYNECOLOGY  OF  OBSTETRICS 

point.  Yet  there  are  some  factors  that  place  the  anterior  relaxa- 
tions in  a  class  more  individual,  and  these  factors  depend  upon  the 
anatomical  relations. 

The  ventral  vaginal-wall  relaxation,  or  so-called  cystocele,  is 
fonnd  in  a  variety  of  forms,  and  frequently  much  confusion  arises 
in  discussions  which  do  not  recognize  these  variations  and  the  rea- 
sons therefor.  Sooner  or  later  all  forms  of  relaxation  develop  into 
a  condition  of  similar  character,  and  most  methods  of  repair  deal 
with  this  final  state.  It  is  often  unrecognized  that  one  may  find  all 
the  symptoms  which  can  be  credited  to  a  cystocele  occurring  in  an 
individual  in  whom  there  is  no  external  protrusion,  yet  back  of  the 
vulva  closure  may  be  a  marked  bladder-sag,  evidenced  by  cysto- 
scopic  examination  and  the  finding  of  residual  urine. 

A  cystocele  may  be  of  five  types.  The  most  conspicous  form,  and 
one  always  separable  into  an  individual  classification,  is  the  form 
that  occurs  with  a  uterine  prolapse.  Naturall}^,  on  account  of  the 
attachment  of  the  bladder  to  the  true  cervix,  a  sagging  of  the  uter- 
us must  alwa3^s  be  accompanied  by  a  descent  of  the  bladder. 
Whether  this  protrusion  will  involve  the  whole  urethra  as  well, 
depends  on  the  degree  of  prolapse  of  the  uterus  and  the  extent  of 
the  levator-ani  injury.  If  the  segment  of  the  levator  ani  running 
from  the  pubic  bone  to  the  sides  of  the  vagina  around  the  urethra 
and  the  fascia  attachments  of  the  urethra  to  the  pubic  arch  are 
intact,  the  lower  end  of  the  urethra  is  held  up  under  the  arch  and 
a  sharp  flexion  is  present  in  the  canal.  In  such  a  case  it  is  possible 
to  demonstrate  the  muscle  fibers  throughout  their  course.  If  the 
fibrous  attachment  of  the  urethra  to  the  arch  has  given  way,  the 
whole  urethra  will  be  prolapsed  and  the  levator  fibers  will  also  be 
everted. 

Cystocele  with  procidentia  must  be  dealt  with  by  methods  best 
adapted  to  the  correction  of  the  procidentia,  and  consequently  is 
beyond  the  scope  of  this  article.  The  main  causative  factor  here  is 
not  necessarily  the  condition  found  in  other  forms  of  cystocele, 
though  they  are  likely  to  be  associated,  but  it  depends  on  the  in- 
jury that  has  occurred  to  the  uterine  and  vaginal  supports  at  the 
cervical  level. 

Some  men  claim  that  cystocele  is  the  cause  of  procidentia,  and 


tliat  II  is  llic  wciiAiii  ol'  tli<'  hK-uldcr  that  pulls  (If)Wii  tlic  iitci-us.  Tlio 
i-casoii  the  cxsldcclc  foniis,  tlic>-  ar,i;ii(',  is  that,  as  a  result  of  the 
st  rclchiii.i;'  of  the  \-(Milral  \'a,i;iiial  wall  and  iii.jiii->-  to  the  pcriiicuiii, 
the  liladdcr  with  its  incoiiiprcssihlc  li(|uid  coiitciits  prodiu-cs  a  her- 
nia of  that  xisciis.  Were  a  cystocele  always  the  cause  of  pi-ocideu- 
tia,  it  would  he  icasoiuihle  to  expect  every  extensive  cy.stocele  to 
))('  associated  with  prolapse  of  the  uterus. 

Kroni  the  clinical  aspect,  it  is  evident  that  the  nuniher  of  cysto- 
cele  cases  are  out  of  proportion  to  the  j)rocidentiae,  and  that  many 
ventral-wall  i)rotrusions  of  long'  standing  and  excessive  size  are 
unassociated  with  any  sag  of  the  uterus.  On  the  other  liand,  many 
cases  with  the  uterus  prolapsed  to  the  vulva  present  no  marked 
degree  of  cystocele. 

Looking  at  the  subject  from  the  anatomical  basis,  it  is  easy  to 
lind  a  rational  argument  to  explain  the  occurrence  of  a  cystocele 
unassociated  Avith  ])rolapse. 

From  both  stand})oints,  the  clinical  and  the  anatomical,  it  seems 
reasonable  to  account  for  uterine  prolapse  as  a  result  of  injury  to 
structures  at  the  cervical  level.  This  has  alread}^  been  discussed. 

A]iart  from  the  cystocele  ahvays  associated  wuth  procidentia, 
there  are  four  other  forms  of  cystocele  when  classified  according 
to  their  mechanical  etiology.  Naturally,  these  arbitrary  varieties 
may  be  more  or  less  associated  either  with  one  another  or  with 
procidentia. 

Tlie  most  connnon  form  is  the  one  which  results  as  the  outcome 
of  a  general  stretching  of  the  fascia  layers  beneath  the  vaginal 
wall.  It  has  been  showm  that  these  fasciae  have  their  origin,  or 
rather  attachment,  at  the  "  wdiite  line,"  and  that  in  normal  indi- 
viduals the  layers  are  as  firm  as  any  abdominal  layer  and  have,  as 
well,  considerable  elastic  tissue  in  their  composition.  The  nearer  to 
the  "white  line"  our  dissection  is  carried,  tlie  greater  the  rein- 
forcement that  takes  place. 

This  general  stretching  will  usually  result  from  a  too  forcible 
forceps  delivery  or  over-rapid  distention  after  the  child's  head  has 
left  the  uterine  cavity. 

The  second  variety,  and  one  usually  associated  with  the  first, 
depends  u])on  the  injury  of  the  levator-ani  anterior  segment,  which 


124  THE  GYNECOLOGY  OF  OBSTETRICS 

results  in  a  protrusion  of  the  lower  portion  of  the  ventral  vaginal 
wall,  and  possibly  is  better  designated  as  a  nrethroeele.  A  urethro- 
cele, especially  if  associated  with  a  relaxed  vaginal  outlet,  soon 
permits  the  sagging  of  the  upper  ventral  portion  of  the  vaginal 
canal.  If  the  outlet  is  not  much  relaxed,  the  protrusion  acts  as  a 
wedge  to  widen  that  outlet.  This  wedge  action  is  given  by  some 
men  as  the  cause  of  a  recurrence  of  the  cystocele.  The  recurrence 
is  not  on  account  of  the  wedge  itself,  but  is  the  result  of  the  lack  of 
attention  to  the  levator  fibers  at  the  time  of  operation  that  permit- 
ted the  persistence  of  the  wedge. 

The  other  two  forms  of  cystocele  are  comparatively  rare.  In 
one  class  of  cases  a  split  in  the  fascia  layers  j)ermits  a  true  her- 
nia of  the  bladder  or  the  urethra,  or  of  both,  as  can  be  evidenced  by 
palpation  of  a  hernia  ring.  In  the  other  class  the  lateral  vaginal 
supports  have  given  way  at  their  attachment  along  the  ' '  white 
line. ' ' 

George  R.  White,  of  Savannah,  in  an  article  on  cystocele  has 
classified  under  three  heads  the  generally  accepted  theories  of 
bladder  support  and  cystocele  causation,  though  he  believes  that  of 
these  theories  none  are  correct : 

"1.  Cystocele  is  due  to  overstretching  and  thinning  out  of  the 
ventral  vaginal  wall  and  other  supports  of  the  bladder,  which  al- 
low the  bladder  to  descend  in  the  form  of  a  hernia.  The  condition 
is  caused,  or  at  least  increased,  by  the  relaxed  perineum,  which 
leaves  the  ventral  vaginal  wall  unsupported. 

' '  2.  The  bladder  is  supported  in  part  at  least  by  its  firm  attach- 
ment to  the  uterus,  and  when  this  attachment  is  overstretched  or 
broken  during  labor,  or  otherwise,  the  bladder  descends  as  a  cysto- 
cele. 

"3.  The  bladder,  like  the  stomach  and  other  abdominal  organs, 
is  suspended  by  ligaments,  which  are  attached  below  to  a  relatively 
inelastic  portion  of  the  bladder,  and  above  along  the  obliterated 
hypogastric  arteries  and  the  uterus." 

This  classification  expresses  fairly  well  the  varying  opinions  re- 
garding the  causation  of  cystocele.  With  none  of  these,  however, 
does  White  agree,  and  his  reason  for  believing  that  the  cause  of  the 
ventral-wall  relaxation  is  due  to  an  injury  along  the  ' '  white  line  ' ' 
is  that  in  a  repair  done  according  to  his  method  the  vaginal  wall 


Plaik  XIV 

THE  VENTRAL  SEGMENT  OF  THE 
LEVATOR-ANI  MUSCLE 


AND 


A  section  through  the  pelvis  at  the  symphysis 
pubis.  The  urethra,  vagina,  and  rectum  have  been 
drawn  downward;  the  layers  of  fascia  covering 
the  levator  ani  have  been  cut  away  to  near  their 
line  of  attachment  at  the  ' '  white  line. ' '  The 
ventral  segment  of  the  levator  ani,  having  its 
origin  mainly  from  the  pubic  bone,  is  shown 
blending  into  the  muscle  structures  of  the  pelvic 
floor  and  the  sides  of  the  urethra  and  vagina. 
The  blue  area  represents  the  attachment  at  the 
"  white' line  "  of  the  middle  and  dorsal  segments 
of  the  levator  ani. 


iufi^  J--?ji 


cvs^rocKi.K  i2r) 

fits  into  tlic  space  ()i'i,i;iiiall>'  occup'kmI  witlioiit  i-(Mliiii(laiK'\'  and 
witliout  the  necessity  Tof  any  resection. 

To  snppoit  this  tlieoi-)-,  lie  claims  that  thickeiiinij,-  ol'  the  pfotnid- 
in,U'  structufes  takes  place  instead  of  thinning',  as  shonld  occui-  with 
stretchinii,',  and  fui'thej',  that  the  pei'ineal  siii)])oi't  as  a  pi-o|)  to  the 
venti'al  wall  is  disproved,  because  in  complete  rupture  of  the  peri- 
neum cystocele  is  rare. 

We  have  shown  that  tlie  ui'ethra  is  attached  undei-  the  puhic  arch 
liy  lirm  fascia  hands;  that  between  the  vaginal  nuicous  membrane 
and  tlie  urethra  is  a  firm  layer  of  fascia  stretching'  across  the  pelvis 
from  side  to  side.  This  fascia  layer  has  its  origin  on  each  side  at 
the  i)nl)ic  lione,  along  the  "white  line"  and  at  the  spine  of  the 
ischium,  these  attachments  corresponding  to  the  origin  of  the  leva- 
tor ani.  The  fascia  layer  beneath  the  dorsal  vaginal  wall  has  its 
origin  along  the  same  line,  and  thus  reinforces  the  portion  of  this 
shelf  at  the  sides  of  the  vagina. 

The  first  segment  of  the  levator-ani  nmscle,  which  runs  from 
the  pubic  bone  to  the  sides  of  the  urethra  and  vagina,  is  reinforced 
by  the  layers  of  the  triangular  ligament,  and  thus  supports  the 
lowT^r  portion  of  the  ventral  vaginal  wall.  These  structures,  with 
the  attachment  of  the  urethra  to  the  under  surface  of  the  pubic 
arch,  carry  the  Aveight  ventral  to  the  perineal  body.  The  attach- 
ment of  the  bladder  to  the  uterus  aids  in  the  support  of  the  upper 
portion  of  the  vaginal  ventral  w^all.  Between  these  two  reinforced 
segments  there  is,  in  a  normal  individual,  no  other  direct  muscle 
support  needed,  for  the  middle  and  dorsal  segments  of  the  levator 
ani,  running  dorsal  to  the  vagina,  keep  its  tw^o  w^alls  in  close  touch, 
and  thus  act  as  a  support  to  this  unreinf  orced  section.  The  oblique 
direction  of  the  vagina  in  the  pelvis  in  relation  to  the  center  of 
gravit}^  is  what  permits  the  levator  ani  to  functionate  in  this  w^ay. 
Normally,  the  muscle  structure  of  the  vagina  itself  nmst  also  enter 
largely  into  the  support  of  the  fascia  layers  on  account  of  its  close 
blending  to  the  fasciae  and  the  presence  of  much  elastic  tissue. 

In  a  cystocele  that  is  not  associated  with  a  uterine  displacement, 
and  in  which  the  lower  portion  of  the  urethra  is  in  place,  it  is  evi- 
dent that  the  factor  at  fault  is  a  stretched  ventral  w^all,  wdiich,  un- 
supjiorted  by  the  perineum,  does  not  properly  recuperate.  In  a 


126  THE  GYNECOLOGY  OF  OBSTETRICS 

complete  tear  of  the  perineum  the  reason  we  do  not  always  find  a 
cystocele  associated  is  that  the  force  exerted  during  labor  has 
expended  itself  in  splitting  the  pelvic  diaphragm  dorsally,  and  the 
head  consequently  has  not  crowded  down  the  upper  vagina  or  ex- 
cessively distended  the  canal.  These  cases,  if  left  unrepaired  a  suf- 
ficient length  of  time,  must  result  in  a  sag  of  the  ventral  wall  sooner 
or  later.  Nor  do  they  offer  any  proof  against  the  value  of  the  peri- 
neal supj)ort  of  the  ventral  vaginal  wall. 

The  hypertrophy  of  the  mucous  membrane  that  always  occurs 
in  the  first  stage  of  cystocele  and  rectocele  gives  us  no  grounds  for 
arguing  against  an^^  stretching  of  the  fasciae,  for  the  thickening 
that  results  from  the  congestion,  due  to  friction  and  exposure,  is 
that  of  the  mucous  membrane  alone.  As  the  age  of  the  patient  ad- 
vances, the  normal  atrophy  of  the  mucous  membrane  supervenes, 
and  the  wall  between  the  bladder  and  vaginal  cavities  becomes  ex- 
cessively thinned.  In  such  a  thin-walled  cystocele,  were  Ave  to  fol- 
low a  method  of  attaching  the  sides  of  the  vagina  to  the  "white 
line,"  as  advocated  by  White  and  others,  we  should  be  depending 
on  the  weakest  portion  of  our  cystocele  wall  for  the  holding  up  of 
the  bladder,  and  would  be  open  to  the  same  criticism  that  has  been 
offered  to  the  Emmet  perineorrhaph}^ 

If  we  grant  that  a  cystocele  formation  is  due  to  a  tearing  at  the 
"white  line,"  we  should  expect  to  find  in  all  cases  a  vagina  in 
which  the  anterior  column  and  the  rugae  of  the  mucous  membrane 
are  not  obliterated  or  even  smoothed  out,  or  at  least  not  until  the 
weight  of  the  bladder  has  produced  an  extensive  protrusion,  and 
then  the  attachment  at  the  "  white  line  "  must  necessarily  be  com- 
bined with  a  denudation  method. 


CORRECTION  OF  CYSTOCEFJ] 

I 'I'  IS  «;('ii(M-nlly  i-(H'(ji;iiiz(Ml,  and,  I  think,  with  Justice,  tliat  a 
iiiihl  (Icuicc  of  cystoccle  will  be  taken  caic  of  by  a  i)i-opei" 
perineon-haphy  that  builds  up  a  lii-ni  perineal  body,  especially 
provided  that  the  uterus  is  in  position,  or  is  so  placed  and  kept. 
llo^vever,  the  presence  of  an  enlari>,ed  sa<2,'^in^'  cervix,  if  left  im- 
con-ected,  tends  to  bear  down  on  the  dorsal  vaginal  wall  and  dis- 
turb the  perineal  su])port  of  the  ventral  wall.  This  distui-bance  of 
the  support,  together  with  the  tendency  of  the  bladder  to  sag,  on 
account  of  its  close  attachment  to  the  cervix,  favors  the  develop- 
ment of  the  cystocele,  no  matter  how  thoroughly  the  perineal  re- 
pair is  done. 

If  a  separation  of  the  attachment  of  the  urethra  to  the  pubes 
and  the  stretching  of  the  ventral  segment  of  the  levator  ani  have 
occurred,  and  are  not  corrected,  it  is  only  to  be  expected  that  the 
urethrocele  will  grow  and  be  followed  by  a  cystocele,  even  with  a 
perfect  perineorrhaphy,  since  it  is  evident  that  the  perineum  offers 
no  su])i)ort  to  the  vestibule,  and  the  urethrocele  acts  as  a  wedge  in 
dilating  the  vaginal  outlet. 

The  patient  who,  in  bearing  down  or  straining,  forces  out  the 
ventral  vaginal  wall  requires  some  degree  of  correction  of  the  re- 
dundancv^  The  greater  the  protrusion,  the  more  extensive  nmst  be 
our  bladder  separation  and  support. 

It  is  questionable  whether  at  any  time  during  labor  a  marked 
separation  takes  place  at  the  attachment  of  the  uterus  to  the  blad- 
der. For  while  this  attachment  is  always  loose  and  easily  separated, 
no  matter  how  severe  the  degree  of  cystocele  or  prolapse,  the  nor- 
mal area  of  union  is  not  lessened,  nor  are  the  ureters  or  their  ori- 
fices distorted,  as  should  occur  with  such  an  injury.  Again,  the 
cavity  of  the  cystocele  does  not  detract  from  the  capacity  of  the 
bladder,  but  adds  to  its  capacity  that  additional  area.  It  is  evident, 
then,  when  we  consider  these  two  facts,  that  the  area  which  has 
i>'one  into  the  formation  of  the  cvstocele  cavitv  nmst  have  come  as 


128      THE  GYNECOLOGY  OF  OBSTETRICS 

a  stretcMng  of  the  vaginal  and  bladder  walls.  The  stretching  of  the 
bladder  wall  has  occurred  at  the  expense  of  the  sides  of  the  bladder 
rather  than  the  fundus,  or  base.  An  operation,  then,  which  will 
separate  the  bladder  from  the  vagina  and  so  allow  its  contraction, 
and  thus  its  better  support,  is  most  reasonable ;  but  only  in  exces- 
sive relaxation  does  a  complete  separation  from  the  uterus  seem  to 
be  warranted. 

The  circular  reefing  stitch  in  the  bladder  itself  after  denudation, 
if  used  in  a  moderate  degree,  does  not  form  an  inverted  cone  within 
the  bladder  cavit}^  as  so  often  stated  by  many  men  as  their  objec- 
tion to  that  type  of  operation,  but  simply  helps  to  give  the  circular 
muscle  fibers  of  the  bladder  their  normal  points  of  attachment, 
with  the  proper  limits  of  action,  which  thus  develops  their  func- 
tion. It  is  essential,  however,  to  support  this  bladder-reefing  by  the 
fascia  and  vaginal-wall  muscle  reinforcement,  and  below  that  by 
the  perineum. 

A  large  cystocele  denuded  but  unseparated  laterally  and  inverted 
hj  a  purse-string  suture  of  broad  area  could  readily  raise  the  neck 
of  the  bladder  relatively  higher  than  the  lateral  sulci  and  shorten 
the  ventral  vaginal  wall  to  an  excessive  degree.  A  correct  support 
of  the  fascia  layer  below  would  eliminate  these  sulci,  though  a  free- 
ing of  the  bladder  lateral  to  the  cystocele  area  permits  a  more  uni- 
form collapse. 

The  types  of  operation  advocated  for  the  correction  of  cystocele 
are  numerous,  and  each  t^^^pe  has  for  its  basis  the  purpose  of  cor- 
recting the  etiological  factor  considered  by  the  various  advocates 
responsible  for  the  occurrence  of  the  protrusion. 

The  methods  of  operation  are  classifiable  into  seven  varieties : 

1.  Those  which  are  done  through  the  abdomen,  such  as  the  sepa- 
ration of  the  bladder  from  the  uterus,  so  as  to  approximate  the  base 
of  the  broad  ligaments  in  front  of  the  cervix  as  a  support  for  the 
bladder.  This  same  operation  is  done  by  Alexandroff  and  Tweedy 
through  the  vaginal  route. 

2.  The  numerous  methods  of  operation  advocated  for  the  cor- 
rection of  procidentia,  Avhich  condition  naturally  is  always  accom- 
panied by  cystocele  and  which  places  the  cure  of  the  cystocele 
wholly  secondary  to  the  procidentia.  These  methods  come  naturally 


coiMJKcriox  OK  ('^'s'r()('^:LK  i^d 

Tor  clisciissioii  iiiidcr  the  head  of  procidentia,  tlioii,L;li,  as  a  rule,  tlie 
opci'atioii  must  include  some  of  the  t_\  pes  of  cori'ection  to  be  con- 
si(le|-e(l   Tor  the  cure  of  cystoceh'. 

.'1.  The  "  interposilion,"  oi'  \a,uinal  fixation  opei'ati()H,wliich  witli 
slii;lit  m()(hlication  is  cr(Mlite(l  to  Alackenrodt,  Wertheim,  Scliauta, 
l)iilii-ssen.  W'atkins.  and  otheis.  'Idiis  metlio<l  of  cystocele  treat- 
ment, ex'en  when  tlie  cystoceh'  is  imassociate(l  with  prohipse  of  tiie 
uterus,  is  of  _i;reat  \'ahie  in  cases  of  extensi\'e  ^■ra(h'  oi-  attenuated 
vai;inal  septa. 

Tliese  thi'ee  ai'hitrary  .groups  ai'e  naturally  bexond  the  sco])e  of 
oui-  \voi-k,  and  conse(|iU'ntly  will  uot  ])e  considered  in  detail. 

Besides  these,  there  ai'e  four  uiethods  which  fall  into  the  eate- 
ii,()ry  of  strictly  plastic  work: 

1.  Deuudatious  done  with  scissors, and  thus  supposedly  confined 
only  to  the  mucous  membrane,  a  i~)oint  upon  which  some  men  lay 
great  stress. 

2.  Denudations  in  which  varying  areas  of  the  vagina  are  resect- 
ed and  in  which  the  depth  of  tissue  removal,  short  of  injury  to  the 
l)ladder,  is  not  considered  of  moment. 

3.  Denudations  associated  with  separation  of  the  bladder  from 
the  uterus  and  the  vagina,  the  degree  of  dissection  and  the  shape 
of  the  area  denuded  being  differentiated  by  the  names  of  the  indi- 
vidual operators. 

4.  The  vaginal  operations  which  plan  to  correct  the  cystocele  by 
incisions  designed  to  reach  the  "white  line  "  and  attach  the  vagina 
thereto. 

One  cannot  emphasize  too  often  or  too  emphatically  the  truth 
that  the  correction  of  a  cystocele  goes  hand  in  hand  with  the  build- 
ing up  of  a  functionating  perineum,  and  no  matter  what  type  of 
ventral  colporrhaphy  is  decided  upon  it  nmst  l)e  combined  with  the 
correction  of  whatever  other  pathology  is  present. 

The  operator  who  does  the  denudation  with  scissors,  removing 
the  mucous  memljrane  in  narrow  strips,  sacrifices  no  tissue  except 
the  nmcous  niem])rane,  so  that  the  basement  membrane,  the  va- 
ginal-muscle layer,  and  the  fascia  between  the  vagina  and  urinary 
tract  are  left  intact,  and  in  the  approximation  of  the  raw  area  all 
the  support  possible  is  given  that  can  come  from  the  reefing  of 


130      THE  GYNECOLOGY  OF  OBSTETRICS 

these  structures.  This  is  strong!}^  recommeuded  by  Graves,  who 
uses  a  somewhat  hexagonal  area  of  denudation,  but  with  an  angle 
running  up  on  either  side  of  the  urinary  meatus.  This  permits 
the  use  of  a  "  crown  "  suture,  which  accomplishes  the  approxima- 
tion of  the  ventral  segment  of  the  levator  ani  under  the  urethra. 
The  illustration  shows  the  method  of  applying  the  other  sutures 
so  as  to  accomplish  the  reefing  of  the  raw  area  in  a  linear  longi- 
tudinal direction  beneath  the  urethra.  Though  not  discussed  by 
Graves  from  this  standpoint,  this  method  takes  advantage  of  all 
the  attenuated  structures  as  well  as  the  lateral  edges  of  the  fascia 
and  the  levator  ani  in  correcting  the  redundancy,  and  on  this  ac- 
count is  one  of  the  most 
rational  denudation  oper- 
ations. 

The  second  method,  con- 
sisting of  flap  removal 
without  wider  dissection, 
o^suru^g  includes  practically  all  of 
the  former  types  of  ven- 
tral colporrhaphy,  such  as 
Sinis's.  These  were  classi- 
fied as  median,  lateral,  or 
bilateral.  The  shape  of  the 
area  denuded  varied  ac- 
cording to  the  character 
of  distention  or  the  whim 
^,    ^,         ,   ^      ^.  of  the  operator.  The  meth- 

ine  Oystocele  Operation. 

Devised  by  Graves.  od  of  closure  was  either 

by  purse-string,  interrupted,  or  continuous  suture,  the  only  aim 
being  the  resection  of  the  redundant  tissue  with  approximation  of 
the  raw  area. 

The  methods  of  flap  removal  with  more  or  less  lateral  separation 
of  structures  are  the  operations  receiving  most  support  at  the 
present  time.  The  surgeon  who  feels  that  the  separation  or  stretch- 
ing of  the  attachment  of  the  bladder  and  the  uterus  is  at  the  foun- 
dation of  the  cystocele  carries  his  dissection  as  high  as,  or  even 
through,  the  peritoneal  fold  and  elevates  the  loosened  bladder  upon 


("()liRK("n()\   OF  ('VS1M)("KLK  131 

the  Nciitral  siii'racc  of  tlic  iilcnis.  Saii,i;(M-,  of  l.('i|)/i,t;-,  who  was  the 
fifst  to  i'('|)oi-t  such  nap-splittiii.i;',  U't't  tlic  ix'ritoncal  cavity  uii- 
o|)('I1(mI. 

The  wide  separation  of  structures  allows  the  contracting-  down 
of  the  l)la(l(ler  waUs  and  i)ei  iiiits  greater  resection  of  tissues,  with 
more  ease  of  fascia  and  vaginal-wall  appi'oxiniation.  I  n  most  of  the 
metiiods  of  this  ciiaracter,  the  incision  is  nuide  in  the  niechan  line 
from  cei-vix  to  meatus,  though  some  few  men  adxise  a  tiansverse 
incision  at  the  bladder  and  cervical  junction. 

The  easiest  way  to  do  the  mucous-membrane  sei)aration  is  by 
means  of  the  blunt  curved  scissors,  such  as  the  Mayo,  inserted 
through  a  nick  in  the  nmcous  membrane  at  the  cervical  end  of  the 
cYstocele,  pushed  in  close  under  the  vaginal  mucosa  and  opened. 
Thus  by  blunt  dissection  the  structures  are  separated  ventrally 
along  the  cleavage  lines  to  the  point  desired.  The  membrane  then 
incised  can  be  readily  separated  from  the  sides  of  the  bladder  by 
gauze  dissection  with  a  few  nicks  of  fascia  bands.  All  fascia  struc- 
tures should  be  retained  as  an  added  element  of  support. 

The  methods  of  suture  application  are  various.  Some  advocate 
the  purse-string  of  catgut,  or  even  silk,  to  invert  the  bladder,  re- 
inforced by  continuous  or  interrupted  catgut  or  silkworm  gut,  clos- 
ing the  vaginal  walls  in  a  linear  direction  after  the  redundant  por- 
tion has  been  resected.  Others  do  all  the  suturing  with  one  or  two 
layers  of  interrupted  sutures. 

No  method  gives  better  results  than  the  type  of  continuous  silk- 
worm-gut suture  applied  in  layers,  as  in  the  Somers  perineor- 
rhaphy. We  can  approximate  in  this  way  the  ventral  segment  of 
the  levator  ani,  the  lateral  fascia  edges,  and  finally  the  vaginal 
membrane.  We  are  not  necessarily  compelled,  except  in  extensive 
relaxation,  to  carry  the  separation  broadly  in  order  to  be  able  to 
unite  these  same  structures  by  this  method. 

The  theory  of  White,  that  all  cystoceles  are  the  result  of  injury 
at  the  "  white  line,"  has  led  him  to  devise  an  operation  for  the  pur- 
pose of  correcting  this  supposed  defect,  and  this  offers  the  seventh 
method  of  operation  for  cystocele. 

"  The  vagina  is  held  open  by  two  retractors,  the  ischiatic  spine 
located  by  palpation  and  an  incision  from  one  to  two  inches  long 


132  THE  GYNECOLOGY  OF  OBSTETRICS 

made  through  the  nincous  membrane,  parallel  to  the  '  white  line  ' 
and  extending  well  up  the  vagina.  The  bladder  is  separated  from 
the  vagina  by  blmit  dissection  until  the  spine  of  the  ischium  and 
'  white  line  '  are  reached  and  can  be  felt  uncovered  beneath  the 
finger.  Hemorrhage  is  seldom  troublesome  and  can  be  controlled 
by  a  few  minutes'  pressure.  The  sutures,  which  are  of  chromicized 
catgut,  are  passed  under  guidance  of  the  finger  b}^  a  Deschamps 
handle-needle.  The  first  suture  goes  back  of  the  '  white  line '  just 
as  it  joins  the  spine  of  the  ischium.  The  handle-needle  is  taken  off, 
and  each  end  of  the  suture  threaded  on  a  separate  needle;  one 
needle  is  passed  from  within  out  through  the  median  edge  of  the 
incision,  taking  a  firm  hold  on  the  vagina;  the  other  needle  is 
passed  in  a  similar  manner  through  the  lateral  edge  of  the  incision. 
The  two  ends  are  then  clamped  and  are  read}^  to  be  tied.  A  similar 
suture  is  placed  half  an  inch  lower  down  on  the  '  white  line, '  and 
when  this  is  in  place  both  sutures  are  tied,  bringing  the  lateral  sul- 
cus of  the  vagina  in  contact  with  the  '  white  line '  of  the  pelvic 
fascia. 

' '  Should  there  be  any  prolapse  at  the  outlet  of  the  vagina,  the 
incision  may  be  extended  down  alongside  of  the  urethra  and  the 
vagina  sutured  to  the  dense  fascia  covering  the  pelvic  bone.  The 
opposite  side  is  treated  in  a  similar  manner,  and  when  both  sides 
are  tied  the  anterior  vaginal  wall  is  drawn  up  in  a  normal  position 
and  has  no  tendency  to  sag,  even  when  the  patient  coughs  or 
strains.  The  vagina  reaches  across  from  one  ischiatic  spine  to  the 
other  without  any  tension;  it  collapses  when  the  retractors  are  re- 
moved and  normal  relations  of  the  parts  are  restored. 

' '  The  operation  is  always  done  in  combination  with  other  plastic 
operations,  and  does  not  interfere  in  any  way  with  them,  nor  does 
it  minimize  the  caliber  of  the  vagina,  which  is  a  matter  of  impor- 
tance should  extensive  denudations  be  contemplated  for  a  recto- 
cele. " 

We  have  already  criticized  White's  claims  regarding  the  causa- 
tion of  cystocele.  Provided  we  acknowledge  his  reasoning  in  any 
particular  case,  his  method  of  operation  has  no  objection,  since  it 
rests  upon  an  anatomical  basis.  A  criticism  of  the  operation  would 
question  his  claim  regarding  the  etiology  and  the  permanency  of 
the  results. 

In  extensive  cystocele  protrusion  in  which  ordinary  methods  of 
operation  seemed  to  offer  little  hope  of  cure,  the  complete  oblitera- 
tion of  the  vagina  has  been  done.  While  this  will  naturally  prevent 


CORRKCTIOX  OF  CVSTOCKLK  133 

tlie  Ji(M-iiia  hcyoiid  the  I'iiiia  pudejuii,  it  (iocs  not  i'Lilly  correct  the 
bladder-saii,-  nor  the  residual  urine.  Neither  is  it  inclusive  in  the 
considcintioii  of  coiiscM'vativc  jjlastic  work. 


POST-OPERATIVE  TREATMENT 

THE  after-care  of  patients  upon  whom  plastic  work  of  the 
cervix  and  vaginal  walls  has  been  clone  is  not  very  elabo- 
rate. In  fact,  the  less  interference  the  better  the  results. 
There  are,  however,  a  few  points  in  the  nursing  that  are 
vital  for  the  success  of  the  work  and  the  comfort  of  the  patient. 

These  patients,  as  a  rule,  are  not  excessively  nauseated  and  the 
danger  of  shock  is  slight.  The  degree  of  nausea  will  always  depend 
on  the  variety  of  the  anesthetic,  the  sensibilities  and  preparation 
of  the  patient,  and,  above  all,  upon  the  ability  of  the  anesthetist. 
Usually,  these  patients  need  no  opiates,  for  pain  is  seldom  severe 
enough  to  warrant  their  use.  The  elimination  of  drugs  of  this  char- 
acter will  do  much  toward  rapid  cessation  of  nausea. 

While  there  are  many  drugs  lauded  for  their  ability  to  check 
vomiting,  there  are  few  that  have  any  great  reliability.  The  later 
theories  for  the  causation  of  post-anesthetic  vomiting  abandon 
the  idea  that  it  is  due  to  the  secretion  of  the  anesthetic  in  the  stom- 
ach, and  argue  that  it  is  a  resulting  acidosis,  producing  a  brain 
edema,  and  that  this  edema  is  exaggerated  by  the  use  of  opiates, 
although  these  temporarily  quiet  the  patient.  Fischer,  who  advo- 
cates this  view,  therefore  recommends  the  free  use  of  alkalies  pre- 
ceding and  following  operation,  or  the  use  of  fruit  acids,  which  in- 
directly accomplishes  the  same  results. 

Bicarbonate  of  soda  in  plenty  of  hot  water  will  often  check  the 
nausea,  though  as  a  rule  the  first  glass  is  rejected.  The  same  is  true 
of  tincture  of  iodine,  four  drops  to  a  tumbler  of  water.  If  these  are 
followed  by  sodium-diethylbarbiturate  (sold  under  the  various 
trade  names  of  sodium-veronal,  medinal,  and  calmine),  in  a  dose  of 
from  two  and  a  half  to  five  grains  dissolved  in  a  little  water,  the 
complete  settling  of  the  stomach  is  often  obtained.  This  drug,  if 
given  per  rectum  in  a  slightly  larger  dose,  will  often  accomplish 
the  same  result.  Other  drugs,  such  as  adrenalin  and  olive  oil,  seem 


I>()SM^-()l'Klx\\'n\l^:  TRF.ATMF.XT  135 

to  li('l|)  (X'casioiiall.N-  in  conti-olliii^'  nausea,  hut  there  is  uotliiu^-  that 
is  uiiit'oniily  successrul.  'IMie  use  of  j>,as  and  ()xy<>,'eii  as  an  anesthetic 
nives  souiewliat  h'ss  post-operative  v()initiii<;'. 

Durini;-  the  first  few  <hiys  the  patient  is  often  unahh'  to  ui'inate, 
es|)('<'ially  when  the  work  is  extensive,  and  catheterization  should 
l)e  (h)ne  witli  tiie  .greatest  care  as  to  asejjsis  and  with  the  least  pos- 
sible distur))ance  to  tlie  |)erineuni.  The  separation  of  the  labia  to 
too  ij,reat  an  extent  will  produce  some  degree  of  separation  of  the 
edges  of  the  mucous  membranes,  and  we  shall  lind  that  the  patient 
comi)lains  of  considerable  irritation  at  these  spots,  which,  as  a  rule, 
do  not  heal  by  primary  union,  but  by  granulation.  This  can  be 
avoided  if  the  nurse  will  separate  simply  the  upper  portion  of  the 
vulva,  and  only  sufficiently  to  be  able  to  cleanse  the  meatus  with 
small  pledgets  of  cotton.  The  use  of  a  glass  catheter  is  advisable. 
\()t  only  should  the  nurse  appreciate  the  necessity  for  asepsis  in 
catheterizing,  but  in  her  care  of  the  patient  she  should  be  careful 
to  leave  the  stitches  absolutely  alone.  Interference  with  them,  while 
it  may  not  influence  the  results  of  the  operation,  will  have  a  marked 
effect  on  the  union  of  the  mucous  membrane,  and  consequently  on 
the  comfort  of  the  patient.  The  necessity  for  continued  catheteriza- 
tion is  often  due  to  the  reflex  irritation  resulting  on  account  of  the 
prevention  of  primary  union  of  the  mucous  edges  by  careless 
handling. 

If  the  patient  can  void  urine,  the  only  vulvar  cleansing  necessary 
in  the  first  days  is  the  pitcher  douche.  Urine  itself  is  not  injurious 
to  the  healing  process,  and  the  vaginal  discharges,  unless  infected, 
are  rather  more  antagonistic  than  otherwise  to  germ  life.  The 
cleansing  with  the  stream  of  water  will  do  all  that  more  strenuous 
but  misdirected  handling  can  do,  without  the  danger  of  irritation. 

A  i)itclier  douche  of  sterile  water  is  sufficient,  though  I  prefer  to 
add  lysol  or  some  ingredient  of  that  character,  not  so  much  be- 
cause of  its  claimed  antiseptic  value  as  on  account  of  its  alkaline 
and  soapy  action  in  dissolving  the  secretions  and  counteracting 
any  excessive  acidity  of  the  discharges.  xV  normal  salt  solution  or 
a  weak  solution  of  bicarbonate  of  soda  will  have  practically  the 
same  effect.  In  all  cases  a  sterile  solution  should  be  insisted  upon, 
even  if  an  antiseptic  is  added. 


136  THE  GYNECOLOGY  OF  OBSTETRICS 

When  the  patient  complains  of  more  than  nsual  soreness  and 
pain,  hot  compresses  for  a  short  time  to  the  vulva  will  not  inter- 
fere with  the  healing  and  will  often  relieve  the  discomfort.  These 
compresses  may  consist  of  the  extract  of  hamamelis  or  of  lead- 
water  and  opium. 

In  all  his  vaginal  operations  Gushing  used  an  ointment  com- 
posed of  morphine  and  cocaine,  one  grain  of  each  to  the  ounce  of 
zinc  ointment,  and  at  the  completion  of  the  operation  he  partially 
filled  the  vagina  so  that  the  slow-melting  ointment  kept  the  parts 
continually  covered.  Such  treatment  as  a  routine  is  unnecessary, 
but  in  some  cases  of  irritation,  and  especially  if  there  has  been 
any  interference  with  the  anus,  the  use  of  this  ointment  will  give 
marked  relief  without  producing  as  much  toxic  effect  as  supposi- 
tories. ' 

In  a  case  showing  considerable  swelling  and  induration,  coming 
on  shortly  after  operation,  the  use  of  an  ointment  composed  of 
guaiaeol,  ichthyol,  and  belladonna  will  often  afford  great  relief 
and  possibly  prevent  a  pus-formation  process. 

In  all  cases  of  plastic  work  within  the  vagina,  there  is,  at  about 
the  end  of  the  first  week,  a  marked  increase  in  the  amormt  of  the 
discharge,  which  is  probably  due  to  the  presence  of  the  absorbable 
sutures  in  the  normally  moist  tract,  and  this  discharge,  especially 
when  not  profuse,  on  account  of  its  delayed  exit  becomes  markedly 
odorous.  The  increased  leucorrheal  discharge,  the  result  of  the 
aggravated  endocervicitis,  recognized  by  Emmet  as  often  following 
trachelorrhaphy,  has  been  considered  under  that  head.  Where  this 
decomposition  of  the  discharge  takes  place,  the  comfort  of  the  pa- 
tient is  greatly  helped  by  the  use  of  a  sterile  water  alkaline  douche, 
given  once  or  twice  daily.  If  the  nurse  is  instructed  fully  as  to  the 
normal  direction  of  the  vaginal  canal,  and  carefully  inserts  the 
douche  point  with  the  water  flowing,  there  is  no  danger  of  injury 
to  the  operated  regions. 

It  is  never  of  advantage  in  these  cases  to  use  as  the  ingredient 
of  either  the  pitcher  or  the  vaginal  douche  a  germicide  of  the  na- 
ture of  bichloride  of  mercury  or  permanganate  of  potash.  These 
agents  coagulate  the  discharges,  and  the  projecting  sutures  col- 
lect the  coagulate,  so  that  the  cleansing  is  imperfect.  Such  drugs 


1^()ST-()]M^]RAT1VE  TTJEATMF.XT  137 

are  often  iiTitatiiiii,' — and  tliis  is  also  true  of  the  crcsol  conipoiiiKls 
wlieii  ust'd  too  stroni;'. 

In  eases  of  re))aii',  where  tlie  spliineter-ani  nniscle  lias  been  unit- 
ed, Kelly's  i-econinieiidation  is  to  keep  tlie  patient's  bowels  at  rest 
I'oi-  ten  days  by  feeding  only  albumen-water  during  that  period, 
and  then  aiding  the  movement  M^th  an  oil  injection  when  the  bowels 
are  inclined  to  act  from  the  laxatives  given  by  mouth.  He  also  in- 
sists upon  the  patient  remaining  upon  her  side  during  the  first 
evacuation.  This  is  a  modification  of  the  older  method  of  keeping 
the  l)owels  closed  with  0]:>iates  during  the  ten-day  period,  which  has 
not  infi'equently  been  the  cause  of  severe  autointoxication. 

In  all  cases  in  my  practice  I  have  used  the  continuous  suture 
method  of  rejiair,  so  that  the  silkworm  gut  reinforced  the  catgut 
approximation  of  the  sphincter  muscle,  a  thorough  stretching  of 
the  nniscle  being  done  previous  to  the  denudation.  I  have  in  no  way 
treated  the  patients  otherwise  than  in  an  ordinary  perineorrhaphy, . 
except  by  exerting  greater  care  to  feed  a  diet  with  small  waste  and 
to  ])rocure  soft  bowel  movements,  and  have  always  had  satisfactory 
results. 

Kelly  and  Noble  report  a  percentage  of  failure  of  one  in  twenty 
in  com]:)lete  perineorrhaphies,  on  account  of  infection.  I  believe 
that  with  the  continuous  non-absorbable  suture  the  percentage  of 
good  results  should  be  much  higher.  So  far,  in  both  recent  and 
secondary  cases,  my  results  have  been  good  where  this  type  of  su- 
ture was  used.  Two  of  these  had  a  mild  degree  of  infection,  yet 
with  successful  results. 

In  all  cases  of  perineorrhaphy  the  best  drug  for  the  bowels  is 
castor  oil,  ])oth  as  a  preparation  and  as  the  first  laxative  after  op- 
eration. The  second  morning  following  operation  a  dose  is  given, 
and  then  if  other  laxatives  are  needed  the  patient's  preference  or 
custom  is  consulted.  In  complete  perineorrhaphies  the  use  of  sul- 
phur and  cream  of  tartar  aid  in  keeping  the  passages  soft. 

Occasionally,  if  much  catheterization  is  necessary,  or  if  there  has 
been  complaint  of  bladder  irritation  before  operation,  urinary  anti- 
septics, such  as  salol,  arbutin,  or  hexamethylamine,  with  demulcent 
drinks,  are  of  service. 

I  am  glad  to  say  that  the  old  method  of  tying  the  patient's  knees 


138  THE  GYNECOLOGY  OF  OBSTETRICS 

together  after  a  perineal  operation  has  been  rather  generally  dis- 
carded, though  some  surgeons  still  cling  to  the  custom.  If  we  con- 
sider the  position  the  patient  occupied  on  the  operating-table  when 
the  work  was  being  done,  it  is  easy  to  see  that  the  patient  can 
hardly  injure  the  operative  results  by  the  separation  of  the  thighs. 
The  strain  from  vomiting,  coughing,  or  hiccoughing  puts  just  as 
much,  if  not  more,  tension  upon  the  pelvic  diaphragm  than  can  be 
applied  by  voluntary  exertion,  so  that  the  attempt  to  restrain  the 
patient  by  tying  the  knees  accomplishes  nothing  but  the  discom- 
fort of  the  individual.  As  a  rule,  the  patient  is  only  too  glad  on  ac- 
count of  the  soreness  of  the  parts  to  restrain  her  own  movements. 
In  immediate  repairs  it  is  well  to  avoid  for  the  first  week  au}^  sud- 
den or  straining  movements,  for  such  might,  especially  in  an  inter- 
rupted-suture repair,  lout  unnecessary  strain  upon  the  united  struc- 
tures and  tend  to  make  the  sutures  cut  through  the  relatively  soft 
tissues. 

It  is  best  not  to  permit  a  patient  to  sit  up  before  the  end  of  the 
tenth  day.  After  that  time  the  parts  are  pretty  thoroughly  united 
and  will  stand  some  tension.  The  sutures,  as  a  rule,  are  left  that 
length  of  time. 

The  patient  should  be  cautioned  against  any  actions  which  will 
put  too  much  strain  on  the  pelvic  diaphragm  for  at  least  several 
weeks  following  the  return  home,  for  while  it  may  have  no  bad 
effect  on  a  well-repaired  perineum,  it  is  just  as  well  to  be  on  the 
safe  side,  and  it  will  aid  in  the  general  recuperation  to  encourage 
rest  and  avoid  overexertion. 

It  is  interesting  to  watch  a  well-repaired  perineum  increase  in 
strength  as  time  passes,  through  the  development  of  the  muscles 
which  had  undergone  considerable  atrophy  by  the  limitation  of 
function.  Without  proper  muscle  support  no  amount  of  care  or 
rest  will  prevent  the  gradual  recurrence  of  the  relaxation. 

So  far  nothing  has  been  said  regarding  the  local  preparation  of 
the  patient  for  the  vaginal  plastic  work.  The  careful  shaving  and 
preliminary  cleansing  of  the  vulva  with  soap  and  water,  followed 
by  two  or  more  copious  vaginal  douches,  are  always  essential.  In 
these  douches  some  operators  use  a  liquid  soap  and  require  the 
scrubbing  of  the  vagina  with  a  mounted  gauze  sponge  while  the 


IM)S'r-()l*KIJATI\'K  TRKATMKXT  139 

solution  is  ruiiiiiiii;-.  l)iit  en  re  must  be  taken  to  avoid  usinji,-  sul'licient 
foi-ee  to  injure  the  mucous  meinbi-aiies.  This  is  followed  by  some 
antiseptic  solution,  and  then  possibly  l)y  stefile  water,  the  douches 
beini;'  rejx'ated  in  the  morning-  before  operation. 

Here,  as  well  as  iji  all  other  operative  work,  the  use  of  iodine 
lias  become  almost  mdversal,  and  applications  of  every  strength 
liave  been  recommended.  Undoubtedly,  iodine  is  a  most  excellent 
])rei)aration  for  emergency  cases  of  all  sorts,  and  especially  dirty 
ones.  But  the  ])endulum  is  beginning  to  swing  the  other  way,  as 
we  are  realizing  that  iodine  has  some  disadvantages.  It  has  been 
shown  recently  in  experimental  abdominal  surgery  that  the  unpro- 
tected iodine-covered  skin  may  carry  enough  drug  to  the  peritone- 
lun  to  cause  firm  adhesions  wherever  contact  has  occurred.  Again, 
cases  of  iodine  dermititis  are  coming  to  light  continually.  Unless 
in  very  weak  solutions,  iodine  as  a  routine  in  vaginal  work  is  not 
wise,  since  the  vaginal  canal  has  much  greater  absorptive  powers 
than  the  skin,  and  in  a  susceptible  patient  sufficient  quantity  of 
the  drug  may  readily  be  absorbed  to  produce  a  systemic  effect. 
Even  a  small  quantity  will  occasionally  produce  a  severe  dermititis 
of  extensive  area  not  at  all  eas}^  to  relieve  and  often  more  uncom- 
fortable to  the  patient  than  the  operative  procedures.  Iodine,  too, 
l)y  the  discoloration  of  the  tissues  rather  interferes  with  the  differ- 
entiation of  skin  and  mucous  membrane  and  hinders  accurate  ap- 
proximations. If  used  at  all,  it  should  be  applied  only  in  weak 
solutions. 

The  vaginal  tract  is  resistant  to  the  germs  which  normally  are 
present  there,  so  that  careful  cleanliness  with  the  exclusion  of  out- 
side sources  of  contamination  through  careful  aseptic  technique 
is  sufficient  to  prevent  infection,  and  too  strong  antiseptic  solutions 
are  to  be  avoided.  By  the  use  of  irritating  solutions  we  may  set  up 
conditions  which  will  favor  germ  development.  If  an  infection  of 
pus-forming  character  is  already  present  in  the  pelvic  tract,  no 
variety  or  quantity  of  antiseptic  or  germicide  will  prevent  a  light- 
ing up  of  the  condition  with  the  probable  failure  of  our  operative 
work.  So  in  all  suspected  acute  or  subacute  processes  our  policy 
should  be  one  of  non-interference  unless  special  indications  arise. 
Here,  as  in  other  surgical  work,  the  knowledge  of  when  to  avoid 


140      THE  GYNECOLOaY  OF  OBSTETRICS 

intervention  or  when  to  postpone  it  is  just  as  niuch  a  criterion  of 
the  surgeon's  skill  as  the  correct  doing  of  the  operation  itself  and 
the  correct  carrying  out  of  the  after-treatment. 


PROGNOSIS  AND  POST-OPERATIVE 
COMPLICATIONS 

NiVr  only  for  tlic  pliysical  1)ut  also  i'oi-  the  iiicutal  wcU- 
ht'ing  of  the  patient  the  i-esiilts  of  eflieieiit  plastic  work 
are  always  good.  The  coiiiplications  that  may  arise  at  the 
time  of  operation  or  later  are  not  man}^  and  can  usually 
he  avoided,  so  that,  when  all  factors  are  considered,  there  are  few 
branches  of  surgery  that  yield  such  uniformly  satisfactory  results. 
The  full  measure  of  improvement,  however,  is  not  felt  before  six 
months  or  more.  While  the  immediate  gain  from  the  support  is 
noticeable  as  soon  as  the  patient  is  upon  her  feet,  through  the  re- 
moval of  the  bearing-down  feeling,  the  better  control  of  the  rec- 
tum, and  the  clearing  up  of  the  bladder  symptoms,  yet  time  is  es- 
sential for  the  building  up  of  the  undermined  nervous  system.  It 
is  no  unusual  happening  to  have  a  patient  return  at  the  end  of  four 
or  five  months  disappointed  that  she  still  feels  nervous,  irritable, 
and  is  readily  tired ;  but  if  our  diagnosis  has  been  complete  and  our 
work  well  done,  we  are  safe  in  giving  assurance  of  the  improve- 
ment that  is  bound  to  come,  and  come  the  more  rapidly  the  greater 
the  physical  care  employed.  Generally,  a  few  months  later  such  pa- 
tients are  only  too  glad  to  report  that  they  never  felt  better  in  their 
lives,  for  the  gain  both  physically  and  mentally  is  well  marked. 
One  patient,  and  one  who  exhibited  not  more  than  the  average  im- 
provement, expressed  her  feelings  thus : 

' "  In  the  face  of  the  great  change  it  would  seem  a  simple  thing  to 
say  that  the  pain  and  weariness  have  stopped — though,  in  truth, 
they  were  no  simple  things  w^hile  they  lasted.  But  it  is  not  only 
what  has  gone,  but  also  what  has  come. 

"  That  miserable  phrase  'female  trouble'  is  such  an  old  one — ■ 
so  old,  so  accepted  that  to  rebel  against  its  inevitableness  is  almost 
to  question  the  eternal  verities !  So  many  days  of  sunshine  and 
wind,  jo}"  of  life  and  work,  flash  of  vision  and  strong  pull  of  en- 
deavor, lost  each  month !  So  many  hours  of  agony,  creeping,  strain- 
ing, crashing  to  the  roots  of  one's  mind — breaking  into  all  the 


142      THE  GYNECOLOGY  OF  OBSTETRICS 

wholeness  of  life  and  peace ! — then  the  drugged  quiet  and  the  light 
going  out. 

"  Nor  is  this  all.  Every  month  a  little  less  strength  to  go  on  with, 
a  little  less  control,  a  little  less  hope.  And  always  gathering  in  the 
background  tense  hysteria.  But  one  was  supposed  to  bear  that.  It 
was  almost  a  womanly  virtue  to  be  frail.  And  certainly  womanly 
traits  to  be  hysterical  and  unreliable ! 

"  One  can  bear  the  pain.  But  it  is  not  right  to  see  the  days  pass 
— empty. 

' '  But  now  life  seems  a  new  chance.  The  pain  and  the  shadows 
and  the  weariness  have  gone.  The  memory  that  was  failing,  failing 
every  time  the  light  went  out,  is  quick  and  true  again.  My  body  is 
my  own  again.  It  does  not  desert  me  when  I  need  it.  It  does  not 
weigh  me  down  when  I  would  forget  it,  I  fight  no  more  devils  in 
the  dark.  I  could  tell  you  all  the  pathological  symptoms,  but  it  is  a 
bigger,  truer  test  to  tell  that  life  is  good,  and  that  the  work  has 
wings. ' ' 

This  sentiment,  though  expressed  a  little  more  graphically  than 
usual,  conveys  an  idea  of  the  general  post-operative  satisfaction  of 
the  patient. 

There  are  a  few  factors  whose  presence  may  interfere  somewhat 
with  the  customary  good  results  and  lead  to  disappointment — fac- 
tors which  we  cannot  consider  as  operative  complications.  For 
instance,  sometimes  in  cases  of  tertiary  or  latent  syphilis  we  find 
to  our  great  disappointment  that,  while  the  results  immediately 
after  the  patient's  convalescence  are  excellent, a  gradual  stretching 
out  of  the  scar  takes  place,  so  that,  without  any  apparent  reason, 
a  considerable  relaxation  has  occurred  with  a  recurrence  of  many 
of  the  nervous  symptoms.  Usually  in  these  cases  the  general  evi- 
dences of  specific  infection  are  not  marked;  otherwise,  operative 
procedures  would  probably  have  been  postponed;  and,  consequent- 
ly, specific  measures  are  not  instituted  in  order  to  prevent  the  bad 
results.  It  may  even  be  that  the  failure  to  obtain  a  permanent  re- 
sult is  the  first  thing  that  leads  us  to  investigate  the  possibility  of 
specific  infection. 

The  same  systemic  infection  may  lead  to  a  failure  in  cervical 
work,  but  here  it  is  expressed  through  a  recurrence  of  the  inflamed, 
hypertrophic  condition  for  which  the  operation  was  undertaken. 
However,  in  specific  infections  involving  the  cervix  we  are  not 


IM)S^r-()PKRATI\'K  ('OMn  J  CATION'S  143 

jiistilMMl  ill  cxciisiiii;-  our  lack  of  realization  of  the  true  pathology, 
as  we  perhaps  may  he  in  perineal  conditions,  for  it  should  always 
be  l)()riie  in  mind  that  cervical  j)athology  result in,<;-  fi-oni  injury 
may  be  aggravat(Ml  in  syphilis.  In  the  luetin  skin  reaction  and  the 
Noguchi  and  \Vass(,'rman  ))lood  tests  we  have  aids  to  a  j)ositive 
diagnosis.  While,  of  course,  o|)eratiou  sooner  or  later  is  essential, 
it  is  wisei-  to  first  ()l)tain  control  of  the  general  condition,  if  we  are 
to  ex])ect  good  results. 

Another  factor  that  has  ah'eady  been  mentioned  is  found  in  a 
small  class  of  cases  of  relaxed  vaginal  (nitlet  in  which  there  is 
excessive  redundancy  of  the  vaginal  walls — not  those  cases  associ- 
ated with  ])]()lai)se  of  the  uterus,  but  a  condition  in  which  the  cer- 
vix remains  at  the  normal  level.  This  redundancy  seems  to  be  a 
relaxation  of  the  tissues  generally,  rather  than  the  result  of  disten- 
tion from  cleavage  injury  alone,  and  the  question  of  its  correction 
is  not  an  easy  matter.  The  building  up  of  the  ventral  vaginal  wall 
and  of  the  pelvic  diaphragm  and  floor  does  not,  as  a  rule,  take  up 
sufficient  slack  to  give  the  vaginal  walls  the  support  required  to 
accomplish  the  desired  gain  in  tone,  especially  in  cases  where  a  flap 
repair  has  been  done.  With  the  ordinary  amount  of  plastic  work, 
the  imi)rovement  is  very  marked,  but  still  there  is  sufficient  re- 
dundant tissue  left,  so  that  when  using  a  speculum  the  walls  crowd 
in  and  make  an  examination  of  the  cervix  difficult.  If  the  patient 
bears  down,  there  is  more  or  less  tendency  to  bulging  of  the  walls, 
even  though  well  supported  by  the  perineum.  This  tendency  of 
protrusion  of  the  walls  has  in  time  an  unfavorable  influence  on  the 
perineum,  and  a  relaxation  of  that  may  occur.  But  previous  to  this 
condition,  on  account  of  the  poor  dorsal  support  of  the  upper  por- 
tion of  the  ventral  vaginal  wall,  the  bladder  is  not  sustained  as  it 
should  l)e,  and  the  cystocele  tends  to  recur,  though  within  the 
vagina. 

When  this  condition  is  due  to  a  general  lack  of  tone  in  the  pa- 
tient, efforts  directed  to  building  up  the  physical  condition,  with 
the  avoidance  of  overexertion,  will  do  a  great  deal  toward  con- 
tinuing the  improvement  started  by  the  operative  work.  The  local 
use  of  depleting  tampons,  to  be  followed  by  astringent  douches, 
which  should  be  of  only  moderate  temperature,  will  aid  much.  It 


144  THE  GYNECOLOGY  OF  OBSTETRICS 

is  not  generally  recognized  that  in  some  women  hot  douches  will 
favor  a  relaxation  instead  of  producing  the  blood-vessel  contrac- 
tion that  the  prolonged  use  of  heat  is  intended  to  accomplish. 
Neither  do  we  always  appreciate  the  excessive  amount  of  xoressure 
that  may  be  exerted  from  above  by  an  improper  corset,  especially 
in  these  cases  of  relaxation.  This  pressure  not  only  interferes  with 
the  venous  circulation,  causing  congestion,  but  it  produces  the  same 
character  of  sagging  and  relaxation  just  considered. 

In  these  cases,  however,  a  better  surgical  support  of  the  vagina 
is  almost  a  necessity,  and  should  be  planned  for  primarily.  If  the 
woman  is  beyond  the  child-bearing  age,  we  are,  of  course,  at  liberty 
to  do  a  much  greater  resection  of  tissue,  and  thus  obtain  better 
support  throughout  the  whole  vaginal  canal.  In  the  child-bearing- 
age,  however,  it  is  often  difficult  to  judge  the  degree  of  denudation 
and  how  much  building  up  of  the  fascia  layers  beneath  the  mucous 
membrane  may  be  done  so  as  to  correct  the  relaxation  but  3^et  al- 
low room  for  a  subsequent  labor  without  the  danger  of  splitting 
the  vaginal  canal.  Fortunately,  most  of  these  patients  have  their 
condition  as  a  result  of  successive  labors  and  are  usually  near  the 
menopause.  If  not,  we  simply  have  to  do  the  correction  as  exten- 
sively as  is  compatible  with  possible  subsequent  labors,  even  if 
later  it  may  necessitate  more  operative  work.  A  woman  who  is 
anxious  to  have  children  readily  agrees  to  possibility  of  reoper- 
ation. In  the  correction  of  this  type  of  relaxation  practically  the 
only  perineal  repair  to  be  considered  is  the  Hegar  type  of  denuda- 
tion, which  allows  for  the  reconstruction  of  the  fasciae  and  the 
support  of  the  rectmn. 

There  is  a  milder  degree  of  relaxation  which  might  be  spoken  of 
as  a  recurrent  type.  The  patient  is  immensely  improved  by  the 
operation,  but  from  time  to  time  has  a  recurrence  of  the  irritable 
bladder  or  the  bearing-down  feeling.  These  cases  are  essentially 
due  to  a  lack  of  tone,  not  always  confined  alone  to  the  pelvic  tract. 
Following  periods  of  overexertion,  either  mental  or  physical,  the 
symptoms  usually  return.  It  is  in  women  who  "live  on  their 
nerves,"  as  the  saying  is,  and  w^ho  are  continually  going  beyond 
the  limit  of  their  strength,  that  we  find  such  a  delayed  period  of 
full  improvement;  and  it  is  not  to  be  wondered  at,  for  it  takes 


I'os'roi'KUATix'K  ('()Mnj(\\^ri().\s  145 

time  foi'  aii\'  hod)-  stnictiirc  in  wliicli  an  ovci-supply  of  blood  lias 
l)e(Mi  incscnl  for  a  coiisidcrahlc  period  to  ceaso  to  rospoiul  througli 
its  still  dilated  xcsscls  to  any  al)noi-inal  stiniulns.  As  time  ))asses, 
if  rccniicnt  congestion  is  avoided,  the  tissues  undei-go  a  perma- 
nent contraction  and  con.gestion  occurs  less  easily.  These  patients 
usually  respond  to  the  simple  depletion  jiiethods  after  a  few  treat- 
ments, but  require  general  supervision  for  some  time,  in  order  to 
])i'evciit,  if  i)ossil)le,  any  abnormal  conditions  in  life  tending  to  i-e- 
duce  the  general  resistance. 

The  innnediate  dangers  at  the  time  of  operation  are  not  many 
and  can  always  be  avoided  with  care.  There  is  some  danger  of  in- 
jury to  the  adjacent  organs — the  bladder  in  ventral  colporrhaphy, 
and  the  rectum  in  dorsal.  Hemorrhage  may  occur  in  any  part  of 
the  work,  but  more  especially  in  the  trachelorrhaphy  and  perineor- 
rhaphy. 

An  entrance  into  the  bladder  and  rectum  need  not,  as  a  rule, 
occur  if  care  is  used.  Where  it  does  occur,  it  is  generally  the  re- 
sult of  too  hasty  handling  of  excessively  thinned  septa  or  struc- 
tures distorted  by  scar  tissue.  I  have,  however,  seen  a  few  cases 
Avhere  the  friability  of  the  mucous  membranes  was  so  marked  that 
the  greatest  care  did  not  prevent  injury  to  the  rectum,  and  some  of 
these  occurred  in  the  hands  of  the  most  skillful  operators. 

When  hemorrhage  takes  place,  it  is  usually  in  the  perineor- 
rhaphies, and  is  of  venous  character,  due  to  injury  of  the  rectal 
plexus.  The  properly  placed  suture  will  readily  control  this  type. 
There  is  a  chance  of  more  severe  hemorrhage,  and  a  hemorrhage 
more  difficult  to  control,  in  the  type  of  operation  which  does  exces- 
sive dissection,  such  as  has  been  discussed  under  perineal  repair.  In 
the  practice  of  the  best  men  I  have  seen  bleeding  start  up  from  a 
location  difficult  to  reach  after  the  completion  of  the  operation,  but 
never  have  I  seen  it  occur  where  the  simple  denudation  was  done 
and  the  muscle  picked  up  without  further  dissection. 

The  secondary  bleedings  from  the  cervix  occurring  shortly  after 
the  recovery  from  the  anesthetic  are  due  to  poorly  placed  or  in- 
sufficiently tied  sutures  in  the  angles,  so  that  care  in  placing  these 
deeper  sutures  will  avoid  that  awkward  sequela.  A  pack  in  the  va- 
gina, in  case  the  complication  arises,  may  be  sufficient  if  the  bleed- 


146  THE  GYNECOLOGY  OF  OBSTETRICS 

iiig  is  not  severe,  though  it  will  endanger  the  perineal  repair  unless 
very  carefully  placed.  If  the  flow  comes  from  a  larger  vessel,  it  will 
necessitate  the  application  of  a  suture  well  out  in  the  angle  of  the 
denudation.  This  is  such  an  annoyance  to  surgeon  and  patient,  on 
account  of  the  necessity  for  more  anesthesia  and  the  danger  of  in- 
jury to  the  repaired  perineum,  that  it  is  always  well  to  inspect 
carefully  every  cervical  repair  before  leaving  it,  and  if  there  is  any 
suspicion  of  bleeding,  to  apply  a  reinforcing  suture  at  that  time. 
We  must  remember  that  the  bleeding  point  is  at  the  deepest  por- 
tion of  our  denudation  and  from  a  branch  of  the  circular  artery, 
and  the  suture  may  need  to  be  applied  even  above  the  denuded 
angle.  Care  in  these  seemingly  minor  points  of  plastic  work  will 
tend  very  largely  to  freedom  from  anxiety  on  the  surgeon's  part 
and  better  results  by  the  avoidance  of  interference  at  unfavorable 
times. 

Secondary  hemorrhage  from  the  cervix  occurring  as  late  as  the 
tenth  day  has  been  mentioned.  The  probability  is  that  the  majority 
of  such  cases  are  the  result  of  infection,  though  I  once  saw  it  hap- 
pen in  a  case  in  which  the  surgeon  removed  the  stitches  before  the 
tenth  day.  Mild  grades  of  infection  in  the  uterus  and  tubes  will 
often  interfere  seriously  with  the  repair  process.  The  absorbable 
sutures  dissolve  much  more  rapidly  in  the  presence  of  infection, 
and  when  they  have  disappeared  we  find  a  granulation  process 
covering  the  denuded  areas  with  only  slight  or  no  attempt  at  union. 
A  little  increased  motion  or  slight  mechanical  interference,  or  even 
the  inflammatory  process  alone,  may  be  sufficient  to  start  a  bleed- 
ing from  the  circular  artery.  To  control  such  bleeding  suturing  is 
necessary,  but  from  this  second  suturing  there  is  little  prospect  of 
a  perfect  cervix. 

The  use  of  absorbable  sutures  of  sufficient  resistance  to  last  over 
ten  days  is  best  in  cases  accompanied  by  perineorrhaphy,  if  there 
is  no  possibility  of  infection,  as  it  is  better  to  avoid  interference 
with  the  perineum  in  the  first  three  weeks.  In  case  no  perineor- 
rhaphy is  done,  or  if  infection  is  feared,  non-absorbable  sutures 
may  be  used,  but  their  removal  should  not  be  undertaken  inside  of 
fourteen  days.  The  cervix  always  looks  more  or  less  irregular  after 
the  removal  of  stitches  on  account  of  the  depressions  left  by  the 


IM)SM^-()I'KRAT1\  K  COM  i*IJ  CATION'S  147 

sutiiics,  i)iit,  as  a  rule,  in  a  few  weeks  the  irrei^ulaiitics  disappear 
and  the  sui-faee  assumes  a  normal  aspect. 

Occasionally,  in  amputation  of  the  cei'vix,  the  di-ainaii,('  suPfers 
interference  tiirouiAli  a  temporary  adhesion  of  tlie  incision  edges, 
and  the  fluids  are  r^^ained  within  tlie  utei-ine  cavity.  Tlie  same 
lack  of  drainage  may  occur  in  a  sim])le  re])air,  if,  by  chance,  the 
uterus  in  ))eiiig  pulled  down  lias  been  displaced  and  left  in  the 
i-etroverted  position.  A  small  clot  lodge(l  in  the  canal  may  also 
have  the  same  effect.  This  retention  of  some  curettage  remnants  or 
menstrual  blood  shows  itself  in  a  few  days  after  operation  with  a 
chill  and  a  sharp  rise  of  temperature,  usually  followed  by  profuse 
])eisj)i ration.  Previoush'^  to  the  chill  there  is  a  slight  elevation  of 
temperature  present,  but,  as  a  rule,  it  has  been  considered  naturally 
as  the  ordinary  operative  reaction.  Such  a  condition  is  readily 
remedied  by  a  vaginal  douche  with  a  few  doses  of  ergot  or  other 
oxytocic.  It  is  to  prevent  such  obstruction  that  the  use  of  a  loose 
gauze  wick  within  the  cervix  in  amputation  was  advised  in  the  op- 
erative procedure.  The  removal  of  this  gauze  at  the  end  of  thirty- 
six  or  forty-eight  hours  leaves  the  canal  patulous.  Also,  it  is  impor- 
tant before  the  patient  leaves  the  table  to  make  sure  of  a  correctly 
placed  uterus  in  cases  in  which  there  is  no  abdominal  work  to  be 
done.  If  the  uterus  is  found  out  of  position  later,  the  knee-chest  or 
Sims's  position  will  usually  correct  the  condition  without  instru- 
mental interference,  though  the  necessity  for  air  entering  the  va- 
ginal canal  must  be  borne  in  mind.  However,  the  less  we  have  to 
interfere  with  our  patients  after  perineorrhaphies  the  better  the 
results  will  be. 

After  the  menopause,  when  the  nmcous  membranes  normally  be- 
come more  or  less  atrophic,  it  is  not  uncommon  to  find  that  adhe- 
sion has  taken  place  lietween  the  ventral  and  dorsal  vaginal  walls, 
or  between  them  and  the  cervix  at  points  on  the  suture  lines.  These 
unions  are  often  fairly  firm,  but,  as  a  rule,  can  be  readily  separated 
with  the  finger  when  the  sutures  are  removed.  If  no  vaginal  ex- 
amination is  made  at  the  time  the  perineal  stitches  are  removed, 
and  the  condition  is  overlooked,  later  on  it  may  be  impossible  to 
separate  the  approximation  without  dissection.  It  is  not  always 
necessary  to  have  two  incision  areas  in  apposition  to  have  such  a 


148      THE  GYNECOLOGY  OF  OBSTETRICS 

complication  arise,  for  the  senile  membrane  itself,  if  injured  by 
friction,  will  readily  unite  with  the  line  of  incision  on  the  opposite 
wall.  In  fact,  in  senile  vaginitis  very  frequently  opposing  areas 
will  become  adherent,  even  without  any  mechanical  interference  of 


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Operation-     Trachelorrhaphy  -  Perineorrhaphy 
Uterus  retroverted-  No  operative  correction. 


A  case  of  retroverted  uterus  with  relaxed  vaginal  outlet  and  a  lacerated  hypertrophied 
cervix.  The  patient  refused  abdominal  operation  or  other  method  for  correcting  the 
retrodisplacement.  The  uterus  becoming  displaced  after  operation,  the  drainage  was 
interfered  with,  and  a  sapremic  condition  resulted.  The  replacement  of  the  uterus 
through  the  knee-chest  position  re-established  the  drainage.  In  these  cases  the  pulse  rate 
is  out  of  proportion  to  the  temperature,  and  the  leucocyte  count  is  not  increased,  factors 
that  are  against  a  diagnosis  of  infection. 

oi^eration,  when  the  lining  membrane  has  become  excessively  thin 
and  friction  has  resulted  in  erosion.  I  have  seen  the  adherence  of 
the  vaginal  walls  occur  in  two  cases  where  there  had  been  con- 


POS^roPKIJATlVE  COMPJ.ICATIOXS  U!) 

si(l(M-al)le  swelliii.i;-  ol'  the  structuros  following-  o])erati<)ii,  and  in 
one  case  wliei-e  union  of  an  aini)utat('(l  cervix  and  a  veiiti'al  coli)or- 
rhaphy  occurred — these  tliree  cases  in  wonien  well  under  the  meno- 
pause and  with  normal  vaginal  walls.  While  such  a  complication 


Juri"   iO'.h  il-.h  12t.i  13th  14'vh  Ibth 

\M  !■  M  A.M.  P.M.  A.M.  P.M.  A.M.  I'.J!  A.M.  PM.  A.M.  P.M. 

4    S  IJ    4  8    rj    4    S  li;    4    S  12     4    .S  12    4    S  1-'     4   S  12     I  6  12    4    S  12    4    8  12    4     8  12    1    S  12 


c  e 


a 

so 
M 

?     lor 


PULSC 


?o      fa      fo    ff         fo  f6 


JO       Si 


to  «3 

Oparation — -  Plsstic  Work  on  Cervix  and  Perinaum. 


1^    %        ^^ 


So    ^0 


In  this  patient  tlie  plastic  work  upon  the  cervix  produced  a  temporary  gluing  together 
of  the  surfaces,  thus  interfering  with  the  drainage.  The  uterine  cavity  had  been  curet- 
ted, but  the  debris  had  been  removed  by  gauze  without  irrigation.  A  vaginal  douche 
with  a  dose  of  ergot  produced  sufficient  uterine  contraction  to  re-establish  drainage. 

is  not  common,  it  is  well  to  bear  the  possibility  in  mind,  and  never 
permit  a  patient  to  leave  the  hospital  without  a  digital  vaginal 
examination,  even  if  the  use  of  absorbable  sutures  has  eliminated 
the  necessity  for  removal.  If  such  an  adhesion  becomes  firm  and  is 
of  any  great  extent,  it  may  give  rise  to  unpleasant  complications. 


150      THE  GYNECOLOGY  OF  OBSTETRICS 

After  plastic  work  it  is  not  at  all  unusual  to  find  a  recurrence  of 
the  menstrual  flow,  even  though  the  patient  has  just  completed  the 
normal  period.  This  return  seems  to  be  largely  due  to  the  reflex 
congestion  of  the  ovaries,  as  a  result  of  the  irritation  of  the  cervix 
by  the  presence  of  the  sutures.  It  is  not  found,  as  a  rule,  if  the 
uterus  and  cervix  are  not  interfered  with.  On  the  other  hand,  it  is 
often  present  after  pelvic  abdominal  operations  where  no  plastic 
work  has  been  done. 

The  question  as  to  what  time  of  the  month  in  relation  to  the 
X)eriods  is  best  for  operative  work  has  usually  been  decided  as 
immediately  following  a  period.  It  is  true,  and  especially  in  the 
abdomen,  that  then  there  is  less  trouble  in  controlling  the  capillary 
bleedings,  but  this  is  probably  the  only  reason  for  choosing  this 
time.  In  plastic  work  the  bleeding  is  freer  during,  or  especially 
just  before,  the  period,  yet  it  is  never  too  great  to  interfere  with 
the  work  or  prevent  ready  control.  It  is  very  questionable  whether 
the  bleeding  from  the  curettage  and  trachelorrhaphy,  if  done  just 
prior  to  a  period,  will  head  off  the  normal  flow.  In  some  cases  it 
will,  but,  as  a  rule,  the  menstruation  is  only  delayed  a  few  days, 
and  then  occurs  probably  on  account  of  the  stitch  irritation  of  the 
cervix. 

It  is  in  acute  or  latent  salpingitis  that  operative  interference 
even  for  simple  plastic  work  must  be  avoided,  for  then  the  traction 
on  the  cervix  necessary  in  repair  work  is  sufficient  to  light  up  the 
inflammation  and  produce  pain  and  temperature  with  often  a  fail- 
ure to  heal.  If  such  a  condition  is  suspected,  the  omission  of  a  cu- 
rettage is  wise;  but  it  is  always  better  to  postpone  any  operative 
work  of  this  non-emergency  kind  until  we  are  sure  of  the  sub- 
sidence of  the  infection. 

The  presence  of  the  gonococcus,  as  a  rule,  does  not  seem  to  in- 
terfere with  the  healing,  yet  it  is  not  safe  to  recommend  operative 
interference  in  its  presence.  Cases  of  suspected  latent  infection  in 
the  glands  of  Bartholin,  unconfirmed  by  microscopical  examina- 
tion, may  sometimes  be  submitted  to  operation  on  account  of  the 
great  improvement  to  be  attained  by  operative  work.  In  a  few  such 
cases  I  have  seen  good  results,  though  considerable  local  reaction 
and  swelling  occurred  immediately  following  operation.  In  each 


I>()ST-()I*KRAT[VK  (*(  )M  PLK 'A^riOXS  IT)! 

case  tlic  coiitiiiiious  suture  was  used  in  the  |>('riu(M)i-rl)a[)iiy,  and  \ 
<|U('sti()ii  wlictlicr  int(Miu|)t(Ml  sutures  would  liav<i  <i,iveu  the  same 
satisfactory  outcome. 

It  is  always  sal'ei-  to  omit  tlie  curettage  if  iidVctioii  is  susj)ected, 
I'oi-  it  nia>  he  just  tlie  iiiitation  siifhcieut  to  light  up  a  tubal  in- 
volvement and  result  in  the  development  of  a  pelvic  abscess.  One 
cannot  too  strongly  condenm  the  tendency  to  interference  in  acute 
tubal  conditions  before  a  complete  subsidence  of  the  infection.  It 
is  not  only  dan.nci'ous  to  the  life  of  the  woman,  l)ut,  if  she  survives, 
is  the  forerunnei-  of  many  pathological  pelvic  conditions.  Few 
women  have  ever  lost  their  lives  l)y  the  conservative  treatment  of 
tubal  infections. 

It  has  ])een  jjroven  conclusively  that  after  a  period  of  time  has 
elapsed,  placed  by  German  anthorities  at  two  years,  the  pus  within 
the  tul)es  becomes  sterile,  thus  permitting  of  safe  intervention. 
The  only  acute  condition  where  operation  is  permissible  is  the  pel- 
vic abscess  formation,  and  that,  by  vaginal  drainages  only.  The 
rare  pyosalpinx  rupture  probably  is  best  treated  in  the  same  way. 
hi  a  ]n'osalpinx  complicating  an  acute  appendicitis,  drainage 
through  the  abdomen  and  cul-de-sac  combined  may  be  necessary, 
in  simple  acute  tubal  infections  I  believe  that  operative  interfer- 
ence is  absolutelv  unwarranted. 


MISCARRIAGE  AND  STERILITY 

IT  IS  generally  recognized  at  the  present  time  that  a  simple 
flexion  of  the  uterns  is  not  sufficient  in  itself  to  offer  a  barrier 
to  the  spermatozoa,  and  thus  prevent  pregnancy.  Either  the 
inflammation  of  the  cervical  mucous  membrane  (which  is  so 
often  associated  with  the  anteflexion)  or  the  infantile  character  of 
the  pelvic  organs  (which  in  varying  degrees  is  at  the  base  of  the 
etiology  of  the  condition)  is  the  factor  that  prevents  conception. 

There  are  cases  unassociated  with  inflammation  where  sterility 
exists,  and  where  it  can  be  overcome  by  a  thorough  dilatation  with 
the  wearing  of  a  stem  pessary.  This  treatment,  however,  is  effec- 
tive more  because  the  presence  of  the  foreign  body  within  the  uter- 
ine canal  stimulates  the  development  of  the  undeveloped  organs 
than  because  of  the  correction  of  the  stenosis. 

Yet,  on  the  other  hand,  Pozzi's  operation,  done  to  enlarge  the  os, 
has  to  its  credit  a  sufficiently  large  proportion  of  sterility  cures  to 
show  that  in  some  cases  the  smallness  of  the  external  opening 
bears  considerable  relation  to  the  absence  of  conception.  This  may 
be  due  directly  to  the  enlarged  opening  permitting  the  spermatozoa 
to  enter  more  readily.  Indirectly  it  may  be  of  value  by  affording 
freer  drainage  of  the  cervical  canal,  and  thus  preventing  its  ob- 
struction by  mucous  plugs. 

The  operation  advised  by  Pozzi  to  correct  sterility  consists  of 
two  lateral  incisions  separating  the  ventral  and  dorsal  cervical 
lips  and  the  closure  of  each  raw  area  laterally  by  interrupted  su- 
tures so  as  to  prevent  reunion.  Pozzi  insists  on  silver  wire  with  a 
cone-shaped  lead  shot  for  this  purpose. 

He  recently  reported  a  large  percentage  of  resulting  pregnan- 
cies, with  no  bad  effects  in  those  cases  not  successful  No  cases  of 
miscarriage  are  reported. 

However,  other  operators  have  had  cases  where  the  after-effects 
were  not  good,  on  account  of  the  irritation  of  the  exposed  mucous 
membrane.  Cases  of  miscarriage  following  incision  of  the  cervix 


AllSC'AliKIA(;K  AND  STP^RIIJTV  153 

(lone  t'of  iiiciisti-iinl  pain  ai'c  not  niicomtiioii,  and  ai-c  in  pi'actically 
the  same  catc.tAoi'N'. 

By  tliis  operation  we  arc  actnallx'  ii,ottini2,'  the  conditions  wliicli 
result  I'loni  a  toi-n  cervix,  tliou,i;li,  of  course,  without  the  scar  tissue 
at  the  angles.  The  ])os>sil)ilities  are  ])reseut  for  irritatiou  of  the  mu- 
cous nieuihrane  through  exposure,  thus  giving  rise  to  the  train  of 
patlioh)gical  processes  already  considered.  The  scar  tissue  in  the 
angle  und()ul)tedly  j)lays  a  very  inii)ortant  ])ai-t  in  the  i)atliology 
and  symptomatology  resulting  from  cervical  injury.  In  order  to 
get  a]i]iroximation  of  the  mucous  membranes  without  scar  tissue, 
Pozzi  carefully  removes  a  wedge-shaped  portion  from  each  side 
so  as  to  ])ermit  of  accurate  approximation.  His  reports  of  good  re- 
sults serve  to  em^Dhasize  the  importance  of  the  scar-tissue  angles 
in  cervical  inflammations.  Possibly  those  operators  reporting  in- 
Hannnatory  sequelae  failed  to  get  perfect  primary  union,  which 
naturally  resulted  in  scar  tissue. 

VieM'ed  as  a  whole,  the  indications  for  an  operation  of  this  kind 
are  narrow.  It  is  never  indicated  in  the  presence  of  any  inflamma- 
tory i^rocesses  or  in  any  pathology  of  the  uterus  or  appendages 
that  might  account  for  the  sterility.  When  done,  it  should  be  done 
with  great  care,  to  avoid  scar-tissue  formation. 

The  same  indications  apply,  though  in  a  somewhat  narrower 
sense,  to  the  Dudley-Reynolds  operation  as  a  cure  for  sterility  in 
anteflexion.  These  operations  may  be  done  even  though  a  chronic 
inflammation  of  the  cervix  is  present,  w^hich  condition  ought  to  ex- 
clude Pozzi 's  method. 
■  The  Dudley  operation,  which  is  a  modification  of  Sims's  discis- 
sion of  the  dorsal  cervical  lip,  advised  for  dysmenorrhea  and  ste- 
rility in  cases  of  uterine  anteflexion,  consists  of  a  median  vertical 
incision  in  the  lip,  extending  through  the  internal  os  and  down  to 
the  uterovaginal  junction;  a  wedge-shaped  segment  is  then  re- 
moved from  each  side,  so  as  to  permit  the  folding  over  and  closure 
by  suture  of  each  raw  area.  The  purpose  of  this  procedure  is  to 
change  the  direction  of  the  external  os  and  make  straight  and  wide 
the  cervical  canal.  Dudley's  modification  was  devised  to  prevent 
the  exposure  of  any  cervical  mucous  membrane  to  vaginal  irrita- 
tion, such  as  often  occurred  with  the  original  Sims  operation. 


154  THE  GYNECOLOGY  OF  OBSTETRICS 

This  Dudley  operation  is  frequently  combined  with  the  Reyn- 
olds, the  latter  being  a  modification  of  Skene's  anterior  incision, 
advocated  for  the  same  indications.  An  incision  an  inch  and  a  half 
long  is  made  transversely  at  the  vesicovaginal  junction  down  to 
the  uterine  tissue.  By  blunt  dissection,  the  bladder  and  uterus  are 
separated  to  a  point  above  the  uterine  flexion.  Then  the  raw  area  is 
united  vertically  without  including  the  uterine  tissue.  This  opera- 
tion lengthens  the  ventral  vaginal  wall  and  straightens  out  the 
uterus,  so  that  the  external  os  points  backward  in  a  more  normal 
direction.    . 

These  two  operations  were  devised  for  the  purpose  of  correcting 
the  mechanical  abnormality  of  the  uterus ;  the  supposition  being 
that  the  pain  would  disappear  because  of  the  more  direct  and  patu- 
lous canal,  and  that  the  sterility  would  be  cured  through  the  same 
factors,  and  the  more  normal  position  of  the  os. 

Recently  Holden,  of  Brooklyn,  reported  the  results  of  forty  of 
the  combined  operations  done  in  a  period  of  over  nineteen  months. 
His  percentage  of  cures  of  the  dysmenorrhea  was  eighty-five;  of 
the  sterility,  twenty-five.  Previously  Breckner  had  reported  seven- 
ty-three cases  in  over  six  years'  time,  with  sixty-five  per  cent  of 
dysmenorrheas  cured  and  twenty-seven  per  cent  of  sterilities  re- 
lieved. All  cases  evidently  included  as  a  primary  procedure  the 
dilatation  of  the  cervical  canal. 

These  reports  are  interesting  from  the  standpoint  of  the  cor- 
rection of  the  sterilit}^  as  well  as  the  relief  of  the  pain.  It  is  a  ques- 
tion, however,  whether  or  not  the  dilatation  alone  would  have 
been  sufficient,  for  we  know  that  a  thorough  dilatation  will  relieve 
these  symptoms,  though  not  alwaj^s  permanently.  These  Dudley- 
Reynolds  operations  would  be  of  more  value  from  the  scientific 
point  of  view  if  they  had  been  preceded  by  an  attempt  to  accom- 
plish the  same  result  by  simple  dilatation.  Of  course,  there  is  no 
doubt  that  the  patulous  os  and  canal  are  obtained  more  certainly 
and  permanentl}^  by  the  Dudley-Reynolds  method,  but,  on  the  other 
hand,  it  is  a  more  exact  surgical  procedure,  requiring  great  care 
for  good  end  results ;  poor  results  are  probably  factors  that  favor 
miscarriage. 

Practically,  I  believe  that  all  that  the  Dudley-Reynolds  method 


:\IIS('ARRIA(iK  AXI)  STKIMLrrV  155 

ac'C()ini)lisli('s  is  tlic  Ix'tlcr  (li-aiiia<;('  of  the  canal.  Tlie  resulting 
drainage  })erniits  a  greater  eliance  for  the  clearing  up  of  the  in- 
flanunation  that  in  the  great  majority  of  cases  of  anteflexion  is 
hack  of  holli  the  dNsniciiori-hca  and  the  st<'rilit\'.  We  have  spoken 
of  the  class  of  nnd('\<'h)ped  uteri  unassociated  with  inflannnation. 
Naturally,  these  are  in  a  somewhat  different  class,  and  are  the 
cases  that  may  he  aide(l  hy  a  stem  i)essary. 

The  relief  of  pain  is  prohahly  largely  the  result  of  obtaining  a 
lai'ger  and  less  rigid  internal  os  through  a  perfect  operation.  With 
a  i)atul()us  internal  os  there  is  less  chance  of  the  menstrual  blood 
collecting  and  causing  clots  within  the  uterine  cavity,  and  thus  pro- 
ducing the  colicky  pains  of  expulsion.  Yet  in  Breckner's  cases  33.3 
per  cent  of  the  dysmenorrheas  were  not  relieved.  It  is  probably 
true  that  the  congestion  present  in  these  pathological  cases  of  ante- 
flexion alters  the  normal  proportion  of  blood,  lymph,  and  mucus, 
and  thus  favors  clotting. 

In  Breckner's  cases  33.3  per  cent  of  the  dysmenorrheas  were  not 
relieved,  though  they  were  all  patients  supposed  to  be  free  from 
tubal  or  ovarian  pathology.  To  be  of  greater  value,  these  case  re- 
ports should  consider  more  in  detail  the  character  and  degree  of 
inflannnation  in  the  cervix  previous  to  operation. 

From  the  pregnancy  standpoint  alone,  we  know  that  the  direc- 
tion of  the  OS  has  little  to  do  Avith  the  prevention  of  conception. 
Eetroversion  is  not,  as  a  rule,  recognized  as  a  cause  of  sterility, 
and  yet  the  os  is  always  out  of  its  normal  direction.  There  are 
many  women  also  in  whom  pregnancy  readily  occurs  in  spite  of 
the  fact  that  the  uterus  is  in  such  extreme  anteflexion  that  in  many 
of  them  it  returns  to  its  flexed  position  after  each  pregnancy.  AVe 
are  surely  justified  in  the  conclusion  that  in  the  far  greater  number 
of  cases  the  symptoms  in  anteflexion  and  the  sterility  are  secondary 
to  the  inflannnation,  and  that  the  cause  of  success  in  curing  these 
conditions  by  the  Dudley-Reynolds  operation  is  the  subsidence  of 
the  inflannnation  by  drainage.  We  shall  find  that  some  patients 
will  l)y  ordinary  local  treatments  get  over  their  inflammations  and 
become  pregnant. 

In  cases  that  have  had  a  chronic  endocervicitis  over  a  long  pe- 
riod, which  has  resulted  in  a  cystic  degeneration  of  the  cervix,  with 


156  THE  GYNECOLOGY  OF  OBSTETRICS 

a  hypertrophy  of  all  the  cervical  elements,  the  mistake  is  not  infre- 
quently made  of  expecting  a  stem  pessary  to  cure  sterility.  An 
operation  that  in  reality  often  amounts  to  an  amputation  or  an 
Emmet  repair,  even  though  the  cervix  has  never  been  injured,  is 
the  only  method  in  such  cases  for  obtaining  relief.  This  has  already 
been  discussed  under  cervical  inflammations.  In  these  cases  it  is 
the  increased  amount,  the  tenacious  character,  or  the  change  in  re- 
action of  the  cervical-gland  secretion  that  accounts  for  the  sterility. 
A  stem  pessary  used  where  the  mucous  membrane  is  diseased  is 
usually  productive  of  more  congestion  and  an  aggravation  of  the 
inflammation. 

The  pathology  of  the  cervix  has  a  very  vital  bearing  on  the  ques- 
tion of  what  might  be  called  a  relative  sterility — that  is,  the  in- 
ability of  a  woman  to  go  to  term,  or  the  non-occurrence  of  preg- 
nancy after  the  first  child.  We  must  ever  bear  in  mind  the  frequen- 
cy of  the  abortion  tendenc}^  in  syphilitic  individuals  and  recognize 
that  disease.  Though  in  most  of  these  cases  the  termination  of 
pregnancy  is  the  result  of  syphilitic  changes  in  the  placenta,  I  be- 
lieve it  is  sometimes  due  to  the  syphilitic  cervix,  and  not  neces- 
sarily dependent  upon  the  placental  pathology. 

Another  cause  of  sterility  in  which,  of  course,  the  cervix  plays 
no  part  is  the  tubal  obstruction  or  distortion  due  to  pelvic  inflam- 
mation. Eliminating  these  two  classes,  I  believe,  we  have  a  very 
great  number  of  relative  sterilities  due  to  cervical  injuries. 

Personally,  I  consider  that  a  most  frequent  etiological  factor  in 
both  the  non-occurrence  of  pregnancy  and  the  occurrence  of  mis- 
carriages is  the  lacerated  cervix,  especially  if  associated  with  the 
resulting  inflammation.  In  many  cases  this  is  further  aggravated 
by  the  relaxation  of  the  vaginal  outlet. 

Very  frequently,  indeed,  a  woman  with  a  lacerated  cervix  or  a 
relaxed  vaginal  outlet,  or  both,  is  advised  to  wait  until  the  child- 
bearing  period  is  over  before  having  the  injuries  repaired.  The 
physician  who  advises  waiting  argues  that,  despite  the  repair, 
there  will  be  a  recurrence  of  the  injuries  at  the  next  pregnancy, 
and  that  little  wisdom  is  shown  in  doing  something  that,  in  his 
opinion,  would  probably  be  undone.  Even  some  of  our  supposedly 
best  authorities  still  recommend  such  a  procedure  and  overlook 


MISCAKKJAGE  xVXl)  STERILITY  157 

tile  possible  I'litin'c  conijjlicatioiis.  Fs  it  not  better  to  do  a  minor 
o|)ei-atioii,  and  fepeat  it  later  slionld  tlie  tears  recur,  if  by  so  doin<^" 
we  are  enabled  to  avoid  j)ossible  miscarriages  and  an  abnost  cer- 
tain majoi'  opei'atiou,  to  say  iiotbing'  of  liaviiii;'  tlie  woman  in  i^ood 
liealtli  pelvically  ''. 

The  likeliJiood  of  as  severe  injuries  with  su))se(iuent  labors  is 
never  so  great  as  with  tlie  first  cluld,  whether  a  good  innnediate  re- 
])air  or  a  secondary  ])erine()rrhaphy  has  l)een  done.  The  profession 
has  been  well  drilled  in  the  theory  that  an  epithelioma  of  the  cei-vix 
has  always  as  a  forerunner  the  lacerated  cervix,  and  as  a  result 
most  severe  cervical  injuries  are  repaired  when  discovered.  But 
lately  even  that  stimulus  to  putting  the  woman  into  at  least  a  par- 
tial state  of  good  health  is  being  assailed  by  many  waiters,  who 
scout  such  a  theory,  claiming  that  cancer  of  the  cervix  never  begins 
in  the  tear.  Statistics  show^  that  cervical  cancer  has  always  been 
preceded  by  dilatation  of  the  cervix,  either  by  labor  or  from  an  op- 
eration. Some  authorities  believe  that  it  is  recurrent  injuries  that 
favor  malignant  developments  of  the  cervix.  Instead  of  belittling 
the  injured  cervix  as  an  etiological  factor  in  cancer  formation,  it  is 
wiser  to  bear  in  mind  the  clinical  evidence.  Perhaps  it  is  unfortu- 
nate that  there  is  not  some  similar  possibility  to  stimulate  perineal 
repair. 

Severe  cervical  injury  with  its  resulting  inflammation  usually 
prevents  pregnancy,  but  its  symptoms  are  sufficiently  marked  to 
attract  attention  and  result  in  repair.  The  moderate  degree  of  in- 
jury Avhich  may  give  few  symptoms,  and  which  more  often  than  not 
is  passed  over  by  the  examiner  as  of  little  significance,  is  the  one 
which  is  frequently  unrecognized  as  a  cause  of  sterility  or  miscar- 
riage, and  this  is  the  type  I  wish  to  emphasize. 

Herman,  of  London,  in  his  book  on  gynecology  advises  the  Em- 
met operation  as  a  preventive  of  abortion,  since  sometimes  patients 
with  deep  lacerations  of  the  cervix  repeatedly  miscarry.  His  ex- 
planation is  that  during  pregnancy  the  body  of  the  uterus  con- 
tracts intermittently,  and  if  the  cervix  is  weakened  by  deep  lacer- 
ations its  normal  power  of  opposing  the  contractions  is  destroyed 
and  abortion  results. 

I  believe  that  more  stress  should  be  laid  upon  the  inflammatory 


158  THE  GYNECOLOGY  OF  OBSTETRICS 

sequence  and  the  stretching  out  of  the  scar  tissue.  Every  injured 
cervix  in  which  the  cleft  persists  has  the  formation  of  scar  tissue 
in  the  angle,  and  as  the  uterus  enlarges  this  scar  tissue  stretches 
out,  weakening  the  supporting  power  of  the  cervix.  If  only  the 
deep  clefts  were  associated  with  the  abortion  cases,  Herman's 
explanation  might  be  sufficient,  but  many  cases  are  not  associated 
with  pathology  of  gross  character  and  the  deep  cleft  is  wanting. 
In  some  of  these  cases  the  inflammation  that  is  secondary  to  the 
scar-tissue  formation,  causing  endocervicitis  and  later  cervical 
hypertrophy,  may  not  involve  the  uterine  body  as  a  whole,  but  may 
extend  high  enough  to  interfere  with  the  placental  development,  as 
the  fetus  grows,  and  favor  placental  separation,  and,  consequently, 
the  termination  of  pregnancy.  In  these  cases  of  border-line  pa- 
thology probably  all  three  factors  are  at  the  base  of  the  frequent 
abortions. 

Practicall}^,  no  emphasis  has  been  placed  on  the  influence  that 
the  relaxed  vaginal  outlet  exerts  in  exaggerating  cervical  defects, 
and  thus  its  consequent  relation  to  this  type  of  miscarriage,  but  in 
many  of  these  patients  the  cervical  repair  would  not  alone  be  suffi- 
cient, for  the  pathology  of  the  cervix  recurs  with  fair  rapidity,  due 
to  the  drag  of  the  vaginal  walls  from  below  and  the  pressure  from 
above,  with  the  resulting  congestion. 

This  same  relaxation  which  favors  the  descent  of  the  uterus 
naturally  tends  to  exaggerate  a  pathology  in  the  cervix.  Under  a 
normal  condition  of  the  perineum  this  degree  of  pathology  might 
not  be  sufficient  to  result  in  abortion.  The  relaxed  outlet  is  seldom 
alone  primarily  the  cause  of  miscarriage,  for  it  is  only  in  the  first 
few  months  that  it  has  any  direct  bearing  on  the  position  of  the 
nterus,  as  that  organ  grows  rapidly  out  of  the  pelvis,  and  then  is 
l^ractically  self-supporting.  But  it  bears  weight  by  its  indirect  ac- 
tion on  the  cervix,  through  the  greater  chance  for  increased  irrita- 
tion by  friction  and  dragging  that  results  in  inflammation.  Thus 
occurs  the  exaggeration  of  what  might,  under  other  circumstances, 
be  minor  pathology.  Consequently,  it  is  just  as  important  to  rem- 
edy the  relaxation  of  the  outlet  as  it  is  to  repair  the  cervix  in  these 
cases  that  are  subject  to  a  too  early  termination  of  pregnancy  or 
to  sterilitv. 


.MISCAIJRIAdK   AXI)  STERTTJTV  l.")!) 

Sterility  is  in  practically  cvcin'  case  the  direct  result  of  the  iii- 
flaiiimatioii  within  the  c('i-\i.\.  This  iiiflainniatioii  fi-equently  alters 
the  chciiiical  icaclioii  of  the  ccrNical  secretion,  hy  which  sperma- 
tozoa are  desti-oycd,  oi-  produces  such  an  incfease  in  the  (puintity 
of  secfction  as  to  form  a  tenacious  mucous  plu.ii,'  of  the  canal.  In 
these  cases  especially  is  it  important  to  re|)air  any  defect  of  the 
])elvic  diai)hrai!,-m  and  floor,  since  these  defects  are  often  the  cause 
of  the  ceivical  inflammation. 

A  history  of  the  following  rathei-  exaggerated  case  will  serve  to 
illustrate  more  forcibly  how  small  a  degree  of  i)athology  may  be 
the  direct  cause  of  the  abortions: 

**  Airs.  A.  R.,  aged  thirty-eight,  was  exceedingly  desirous  of  hav- 
ing children,  and  was  referred  for  an  opinion  as  to  whether  or  not 
a  mild  degree  of  cervical  pathology  was  sufficient  to  account  for  the 
too  early  termination  of  the  pregnancies.  The  menstrual  history 
previous  to  the  first  conception  was  witliout  marked  abnormality, 
and  there  w^as  nothing  in  the  general  history  that  could  influence 
the  pregnancies,  with  the  exception  of  a  rather  marked  recurrent 
anemia  of  transient  duration.  The  first  pregnancy  had  resulted  in 
an  abortion  at  three  months,  and  the  physician  wdio  had  attended 
at  the  time  spoke  of  the  inflamed  and  everted  cervical  mucous  mem- 
brane. A  second  pregnancy,  a  year  later,  had  also  terminated  at 
three  months,  there  being  in  neither  case  any  discovered  cause. 
Conception  occurred  again  a  year  later,  the  fetus  being  carried  for 
six  months,  wdien  labor  again  intervened  without  warning.  The  last 
pregnancy,  which,  like  the  first  two,  ended  at  three  months,  oc- 
curred tAvo  years  ago. 

' '  Pelvic  examination  showed  a  normally  placed  uterus,  slightly 
enlarged,  a  cervix  somewdiat  hypertrophied,  with  an  erosion  on  the 
ventral  lip  and  a  few  Xabothian  cysts.  The  pelvic  outlet  was  some- 
what relaxed,  though  without  any  marked  cleavage  defect. 

"The  suggestion  of  performing  a  cervical  amputation  with  a 
perineorrha])liy  was  gladly  accepted.  Within  two  months  after 
leaving  the  hosjutal  the  patient  was  again  pregnant;  went  through 
a  normal  term  in  excellent  condition  and  with  less  discomfort  than 
during  the  former  pregnancies,  and  delivered  herself  with  only  a 
moderate  degree  of  injury  to  the  perineum.  Throughout  the  preg- 
nancy a  careful  watch  was  kept  on  the  blood,  and  an  iron  tonic  used 
occasionally,  as  had  been  done  in  the  previous  pregnancy.  This 
patient  expressed  herself  as  being  very  conscious  of  the  increased 
sup]iort  from  the  ])erineum  and  the  comfort  obtained  therefrom." 


160      THE  GYNECOLOGY  OF  OBSTETRICS 

This  case  is  an  extreme  one  of  frequent  miscarriage  without  any 
systemic  cause,  and  depends  Avithout  doubt  on  the  cervical  pa- 
thology. 

The  following  history  is  t^^pical  of  a  considerable  number  of 
cases  of  what  has  been  referred  to  as  relative  sterility,  or  sterility 
occurring  after  the  first  pregnancy : 

''  Mrs.  B.,  aged  thirty-two,  had  five  years  ago  an  abortion  at  six 
months,  following  a  fall,  and  no  conception  since.  The  physicians 
consulted  recognized  nothing  abnormal  and  had  no  suggestions  to 
make.  The  general  health  of  the  patient  was  good,  and  the  only 
complaint  was  of  some  increase  in  the  menstrual  flow  foUow^ed  by 
leucorrhea.  Examination  showed  a  normal  pelvis  except  for  a  mod- 
erate degree  of  cervical  injury,  a  slight  eversion  of  the  mucous 
membrane,  with  an  eroded  area  on  the  dorsal  lip,  and  increased 
cervical  discharge.  The  correction  of  the  cervical  pathology  by 
operation  was  followed  some  months  later  by  conception  and  in 
due  time  by  a  normal  delivery. ' ' 

Gross  cervical  pathology  is  generally  recognized  as  a  possible 
cause  of  sterility  or  of  the  too  early  termination  of  pregnancy,  but 
the  minor  degrees  of  injury  or  inflammation  are  too  often  passed 
over,  and  seldom  do  we  hear  of  the  relaxed  outlet  as  of  importance. 
It  is  true  that  many  women,  in  spite  of  marked  defects  in  the  pel- 
vis, bear  children  with  small  inconvenience,  but  this  does  not  alter 
the  fact  that  there  are  women  with  only  slight  defects  who  are  un- 
able to  do  so.  It  depends,  I  believe,  in  a  large  degree  on  the  sen- 
sibilities of  the  individual  to  irritation,  which  is  a  factor  that  must 
always  be  borne  in  mind,  especially  in  pelvic  pathology.  A  condi- 
tion that  will  make  an  invalid  of  one  woman  wdll  seemingly  cause 
no  inconvenience  to  another.  The  modern  woman,  however,  with 
her  wide  interests,  her  intense  life,  responds  readily  to  the  exter- 
nal, mental,  and  physical  stimuli  surrounding  her  at  all  times,  but 
does  so  at  the  expense  of  her  nervous  stability,  and  this  naturally 
favors  a  greater  reaction  to  any  pathological  process.  These  things 
are  factors  that  should  be  taken  into  consideration  in  deciding  upon 
the  advisability  of  operative  interference  in  border-line  pathology. 
With  so  many  strains  upon  the  nervous  system,  it  is  well  to  con- 
sider carefully  the  effect  of  even  a  mild  degree  of  pelvic  inflam- 
mation as  a  cause  of  irritation  to  the  already  overstrained  nerves. 


MISCARRIAGE  AND  STERILITY  161 

The  occ'iirrcMH'c  ol'  |)i-(\uiiaiH'_\-  and  its  uoi'iiial  coiiiijlction  is  at  best 
a  coin])lieat(Ml  process  of  iiatun".  and  it  is  not  snr|)risini;'  tliat  iii- 
flaiiiiiiation  from  even  a  mild  de.iAree  ol'  patliology  iHa\-,  through  the 
alteration  of  tlie  secretions  or  in  some  more  indirect  way,  interfere 
with  the  processes  either  before  or  after  conce])tion. 


0 


BLADDER  INFECTIONS 

XE  phase  of  cystocele  to  which  scant  attention  has  been 
given  is  the  residual  urine  and  its  relation  to  urinary- 
tract  infections.  The  bacteriological  findings  of  the  uri- 
nary tract  in  relation  to  the  various  pathological  condi- 
tions is  a  subject  still  open  to  investigation.  So  far,  even  the 
question  as  to  the  normal  sterility  of  urine  seems  to  be  debatable. 
In  isolated  instances  considerable  work  has  been  accomplished  by 
the  bacteriologist,  but  generally  without  the  collaboration  of  the 
physician. 

Our  writers  of  authority  are  content  with  meager  statements. 
In  the  International  Clinics  of  recent  date  Burnett,  of  Edin- 
burgh, writes : 

"Workers  in  this  field  at  present  are  but  pioneers  and  our 
knowledge  but  scant}^  In  fact,  I  am  more  and  more  convinced  that 
we  have  still  a  wide  field  before  us,  in  the  bacteriological  study  of 
the  urine  in  disease,  and  I  feel  that  the  time  is  not  far  distant 
when  a  bacteriological  examination  of  the  urine  will  be  regarded 
as  of  even  greater  importance  than  ordinary  chemical  investiga- 
tion." 

A¥ood,  of  St.  Luke's  in  New  York,  told  the  writer  he  would  con- 
sider any  bacteria  in  the  urine  pathological.  In  his  book  he  states 
that  the  bacteria  that  may  be  found  in  the  urine  are  very  numerous, 
and  the  important  species  are  the  colon,  typhoid,  streptococcus, 
staphylococcus,  gonococcus,  and  tubercle.  He  emphasizes  the  im- 
portance of  differentiating  the  tubercle  from  the  smegma  bacillus, 
"  as  the  smegma  are  common  in  urine,  and  may  be  even  in  a  cath- 
eterized  specimen.  .  .  .  The  gonococcus  and  the  tubercle  bacillus  are 
the  only  species  in  which  a  morphological  examination  is  of  much 
value."  And  later:  "The  only  morphological  diagnosis  w^hich  is 
allowable  is  unfortunately  confined  to  two  species,  the  tubercle 
bacillus  and  the  gonococcus."  And  again:  "  The  casts  give  positive 
evidence  of  a  kidney  lesion." 


BLADDER  INFECTIONS  163 

Hiss  and  Zinsser  luu'c  nothiii,!;'  to  say  on  the  liactcriolo^v  of  tlic 
vii-inai-y  ti-act  except  to  state  the  necessity  for  a  catlieteri/e(l  speci- 
men. 

()sler's  new  work  i;ives  hut  one  shoi't  j)ara,i;raph  to  hactei'iuria, 
and  hiter  states  as  his  conclusion  that  vaccines  have  been  used  a 
great  deal,  but  with  little  beiieiit. 

(luitei'as  in  his  new  work  says: 

"Althoui^ii  i^'ernis  iiave  been  found  in  tlie  urine  of  liealthy  per- 
sons, the  majority  of  investii2,-ators  state  tliat  tlie  ui-ine  in  health  is 
sterih',  pr()vide(l  it  he  obtained  by  sterile  instruments  and  under 
])r()i)ei-  precauti(nis.  l)urint>'  and  after  infectious  diseases,  j>,-ernis 
are  often  found  in  the  urine. 

"  Exi)erinients  have  proven  that  the  urine  possesses  bactericidal 
proi)erties  in  health  and  have  shown  that  the  absence  of  bacteria 
from  normal  persons  may  mean  that  the  germs  have  been  de- 
stroyed by  virtue  of  this  property.  The  acid  potassium  phosphate 
supi)osedly  being-  the  protector,  the  neutralization  by  alkali  de- 
strovs  its  bactericidal  property.  Possibly,  the  chloride  may  also 
act.'' 

One  of  the  most  elaborate  articles  on  bacteriuria  is  by  Thomas 
R.  I^rown,  in  Osier's  "  Modern  Medicine."  He  states: 

"It  is  important  to  remember  that  the  epithelium  of  this  tract 
is  extremely  resistant  to  infection  and  that  in  the  vast  majority  of 
cases  certain  predisposing  factors  must  be  met  with  before  inflam- 
mation is  set  up.  The  weight  of  evidence,  however,  certainly  points 
to  the  belief  that  the  urine  of  healthy  individuals  if  obtained  under 
careful  precautions  contains  no  bacteria.  That  the  organs  and 
urine  of  absolutely  normal  individuals  are  free  from  bacteria  has 
the  weight  of  authority,  and  thus  at  the  present  time,  at  least,  it  is 
not  fair  to  assume  that  we  may  have  autogenous  infections  of  the 
kidney." 

Judging  from  the  results  obtained  in  bacteriological  examina- 
tions of  practicall}^  normal  urine  in  a  relatively  large  series  of 
cases  in  women,  I  think  that  we  are  justified  in  concluding  that  a 
urine  which  contains  a  few  germs  to  the  cubic  centimeter  can  prac- 
tically be  considered  sterile.  In  only  a  few  examinations  have  we 
found  the  urine  absolutely  free  of  all  germs,  though  what  would  be 
considered  a  normal  urine  will  show  only  a  very  few  to  each  culnc 


164      THE  GYNECOLOGY  OF  OBSTETRICS 

centimeter.  When  the  method  of  collecting,  the  fact  that  the  find- 
ings are  uniform  in  S3^stematic  checking  of  individuals,  and  the  re- 
sults of  ureter  catheterization  are  considered,  I  think  I  am  justified 
in  assuming  that  these  are  not  due  to  contamination  from  the 
urethra. 

We  know  that  in  man}^  infectious  diseases  the  germs  present  in 
the  body  are  eliminated  through  the  urine,  but  give  rise  to  no  symp- 
toms directly  traceable  to  their  presence. 

This  is  also  true  of  many  infections  of  moderate  severity  that 
usually  attract  no  attention  to  the  urine.  In  case  urine  examina- 
tions are  made,  no  chemical  alteration  of  marked  character  is  evi- 
dent, even  though  the  germs  are  present. 

In  order  to  be  able  to  have  a  basis  for  comparing  the  degree  of 
infections  of  the  urine,  we  decided  to  determine  the  number  and 
variety  of  the  bacteria  present  by  plate  cultures.  Through  the  num- 
ber of  bacteria  found  in  each  cubic  centimeter  of  urine  we  believed 
the  variations  in  progress  might  be  recorded.  However,  there  are 
many  factors  that  make  such  determinations  only  relative.  Some 
germs  resist  plate  culture,  thus  making  a  tube  grow^th  essential  to 
check  the  results.  The  quantity  of  urine  secreted  is  bound  to  influ- 
ence the  proportional  number  of  bacteria.  The  length  of  time  be- 
tween the  obtaining  of  the  specimen  and  the  making  of  the  culture 
is  perhaps  of  greatest  significance.  This  is  on  account  of  the  loss  of 
the  normal  bactericidal  property  in  urine  when  left  standing.  In 
pathological  urine  the  germicidal  function  is  already  destroyed, 
and  the  increase  in  the  number  of  bacteria  is  consequently  rapid. 

Normal  urine  has  a  marked  germicidal  action,  which  may  be  due, 
as  some  think,  to  the  various  chemical  substances  present,  or,  as 
others  argue,  to  the  presence  of  a  substance  of  the  nature  of  a  fer- 
ment. The  fact  that  the  urine  loses  its  germicidal  action  a  few 
hours  after  voiding,  and  also  after  the  application  of  moderate  de- 
grees of  temperature,  gives  possibly  more  weight  to  the  ferment 
theory. 

It  is  relatively  easy  to  give  rise  to  an  inflammation  of  the  blad- 
der by  careless  catheterization,  and  it  is  not  unusual  to  find  acute 
cystitis  in  various  forms  of  infectious  diseases.  Such  cases  are  self- 
evident  and  respond  readily  to  the  ordinary  methods  of  bladder 


P>LAI)I)KR  INFECTIONS  165 

treatniciit,  in'oxidcd  they  ai-c  not  ass()('iat<'(l  with  aii\-  ])la(lder  or 
kidney  ptosis.  It*  aii>'  mine  stasis  exists,  tiu^  iiii'ection  is  inofc  tliaii 
likely  to  become  clironic. 

The  cystocele  of  marked  de'-ree  is  seldom  overlooked,  and,  con- 
sequently, is  promptly  treated;  but  there  is  a  type  of  case  on  the 
l)()i(ler  line  which  has  so  far  been  too  often  neglected.  Such  moder- 
ate conditions  will  often  be  diagnosed  as  cystitis  and  ti'eated  as 
such,  but  with  the  etiology  unrecognized  and  uncorrected. 

I  believe  that  in  women  by  far  the  larger  proportion  of  chronic 
inflannnations  of  the  bladder  are  secondary  to  a  bladder  ptosis, 
caused  by  a  relaxed  vaginal  outlet  \vitli  resulting  or  associated 
sagging  of  the  ventral  vaginal  wall.  This  bladder-sagging  may  not 
be  enough  to  give  any  marked  evidence  of  cystocele ;  but  if  it  is  suf- 
ficient to  cause  the  retention  of  an}'  urine,  it  can  be  accounted  of 
sufficient  importance.  Poor  bladder  drainage  may  in  some  cases  be 
due  also  to  a  relative  ptosis  from  a  displaced  uterus.  In  women  be- 
yond the  menopause  the  bladder  symptoms  may  be  the  only  ones 
present,  though  the  misplaced  uterus  was  the  original  pathology. 
It  is  the  condition  producing  residual  urine  that  is  the  direct  etio- 
logical factor  in  the  production  of  most  cases  of  chronic  cystitis  in 
women. 

In  cystitis,  if  the  residual  urine  is  present,  it  is  the  factor  of 
greatest  importance,  since  it  accounts  for  the  return  of  many  sup- 
posedly cured  bladder  conditions. 

Urine  retained  in  the  bladder  for  any  length  of  time  undergoes 
annnoniacal  fermentation,  and,  as  a  consequence,  its  chemical  char- 
acter is  altered.  The  germicidal  action  due  either  to  the  inorganic 
contents  or  a  ferment  ingredient  is  then  destroyed.  It  needs  only 
the  presence  of  some  pathological  germ  coming  from  above  in  the 
urine,  or  introduced  from  below  by  mechanical  interference,  to 
cause  the  inflammation. 

In  a  bladder  wdiose  function  is  interfered  with  any  type  of  medi- 
cation for  cystitis  can  be  of  value  only  as  long  as  it  is  continued, 
since,  as  a  rule,  such  medication  only  inhibits  the  development  of 
the  germ.  If  by  chance  the  germ  is  removed  by  treatment,  the  bene- 
ficial result  endures  only  until  a  reinfection  has  an  opportunity  to 
come  througli  tlie  l)lood  stream  or  from  mechanical  interference. 


166  THE  GYNECOLOGY  OF  OBSTETRICS 

The  following  histories  illustrate  the  effect  of  a  moderate  degree 
of  bladder  ptosis : 

Mrs.  B.,  aged  55.  One  child;  menstruation  ceased  two  3^ears 
ago.  Present  ill-health  dates  from  fall  astride  a  bath-tub  five 
months  ago.  Had  cystitis  twenty  years  before.  The  coccyx  has  been 
removed  and  the  tissue  around  the  perineum  incised  by  a  surgeon 
to  whom  she  had  been  referred  because  of  pain  upon  sitting  down 
and  frequent  urination.  The  operation  exaggerated  rather  than 
improved  these  symptoms. 

She  complains  of  frequent  desire  to  urinate,  especially  when 
seated;  when  lying  on  back  urination  frequency  is  increased,  but 
can  lie  face  downward  with  comparative  comfort ;  feels  well,  but  is 
extremely  nervous  and  depressed.  Pelvic  examination  shows  mu- 
cous membrane  pale  and  atrophic ;  perineum  shows  scar  of  repair, 
but  muscular  support  is  poor ;  considerable  irritation  around  ure- 
thral orifice  and  vestibule ;  small  cystocele ;  uterus  rather  low,  atro- 
phic; bladder  tender.  Cystoscope  shows  bladder  congested,  other- 
wise negative,  except  for  pouching  of  dorsal  wall.  Urine  cloudy, 
alkaline ;  sp.  gr,  1.010 ;  trace  albumin ;  culture  shows  colon  and  pro- 
teus. 

Treatment  consisted  of  vaccine  and  urinary  antiseptics.  A  small 
pessary  was  placed  to  raise  the  bladder.  In  three  weeks  the  urine 
was  perfectly  normal  and  bacteriological  examination  negative. 
The  pessary  corrected  all  other  symptoms,  but  three  weeks  later 
had  to  be  removed  on  account  of  irritation  to  the  senile  mucous 
membrane.  The  discomfort  in  sitting  returned  immediately,  though 
there  was  less  frequency  of  urination  than  before  the  infection  of 
the  urinary  tract  had  been  corrected. 

Two  months  later  the  patient  came,  desiring  operation,  real- 
izing that  the  majority  of  her  symptoms  were  due  to  the  bladder 
ptosis.  The  operation  consisted  of  a  ventral  colporrhaphy  with 
perineorrhaphy  and  abdominal  suspension  of  the  uterus.  This  ac- 
complished permanently  what  the  pessary  had  temporarily,  and 
now,  three  years  later,  the  patient  sends  word  that  she  is  in  good 
health. 

Mrs.  A.  B.,  aged  51.  Has  had  one  child;  ceased  menstruation  at 
thirty-five  years.  Had  just  come  from  college  hospital  where  gyne- 
cologist removed  a  urethral  caruncle  without  an}^  relief  of  symp- 
toms. Complains  of  frequent  urination,  burning  and  pain  on  void- 
ing, backache,  and  a  sense  of  prolapse. 

Examination  shows  considerable  irritation  around  urethra  from 
where  caruncle  had  been  removed.  Vulva  and  inside  of  buttocks 


P>I.A1)I)KI^   INFECTIONS  167 

sliow  pi'iiritus,  prohably  I'l-oiii  siii^ar  in  ui'iiic;  small  cystocele ;  uter- 
us atfopliic,  altlioii^h  in  normal  ])()sition.  Patient  had  attcmjjtcd  to 
empty  bladder  four  times  in  forty  minutes,  but  upon  catheteriza- 
tion six  ounces  of  residual  urine  was  obtained,  the  bladder  wall 
sliuttiuii,'  down  on  catheter  just  as  if  a  stone  were  present. 

Chemical  examination  shows  albumin;  no  sugar;  culture, an  acid- 
forming  streptobacillus.  Cystoscope  shows  a  marked  trabeculation 
and  congestion  of  the  bladder,  a  few  bleeding  spots,  no  foreign 
body,  but  considerable  pouching  of  the  dorsal  wall. 

A  further  report  from  medical  clinic  where  patient  had  been 
under  treatment  confirmed  diagnosis  of  diabetes  mellitus. 

Treatment  consisted  of  urinary  antiseptics  and  vaccine,  vaginal 
canal  being  too  contracted  to  use  a  pessary  as  a  test  of  condition. 
A^accine  finally  cured  the  infection,  and  thus  lessened  the  frequency 
of  urination,  the  patient  being  able  to  retain  urine  two  hours. 

On  account  of  the  diabetes,  an  operation  was  discouraged,  but 
the  i^atient's  discomfort  caused  me  finally  to  do  a  ventral  colpor- 
rhaphy  and  perineorrliaph}^  The  incisions  healed  by  first  intention 
and  resulted  in  a  great  improvement  in  the  local  s3anptoms.  The 
general  physical  condition  was  improved. 

This  patient  claims  that  she  is  well  unless  she  indulges  in  sugar. 

Mrs.  C,  aged  58.  Two  children.  Ceased  menstruation  at  fifty. 
Had  no  pathological  menstrual  history.  Up  to  four  years  ago  was 
fairly  Avell,  but  since  then  has  had  gradually  increasing  trouble 
with  the  bladder.  Complains  of  considerable  pain  just  before  void- 
ing and  frequently  persisting  for  some  time  after.  Also  complains 
of  a  bearing-down  feeling  and  general  distress  in  the  pelvis.  Two 
hours  is  the  longest  interval  between  urinations,  and  at  times, 
when  worried  or  tired,  the  intervals  are  as  short  as  ten  minutes. 
AVent  to  the  Atlantic  coast  two  years  ago  for  medical  advice,  and 
while  there  a  surgeon  removed  a  urethral  caruncle.  Since  her  re- 
turn her  symptoms  have  been  Avorse,  though  she  has  undergone 
the  most  careful,  conscientious  treatment  for  cystitis  at  the  hands 
of  a  competent  physician,  who  referred  the  case. 

Examination  showed  a  slight  degree  of  vaginal  relaxation ;  the 
mucous  membranes  senile;  the  tubercle  of  the  vagina  more  ex- 
posed than  normal,  but  only  a  slight  bulging  of  vaginal  walls  when 
bearing  down.  The  uterus  was  atrophic,  retroverted,  fixed.  There 
was  some  thickening  at  base  of  bladder  and  left  broad  ligament. 
Cystoscope  showed  a  congested  bladder  ^yith  pouching  of  dorsal 
Avail.  The  catheter  gaA^e  tAvo  ounces  of  residual  urine.  The  urine 
had  a  sp.  gravity  1.015,  A\ith  a  trace  of  albumin,  some  pus  cells  and 


168      THE  GYNECOLOGY  OF  OBSTETRICS 

colon  bacillus  infection.  The  kidneys  were  not  palpable,  though 
there  was  some  tenderness  over  the  ureters.  The  fixation  of  the 
uterus  with  the  small  vaginal  canal  prevented  the  use  of  a  pessary. 
The  operation  consisted  of  a  ventral  colporrhaphy  and  a  peri- 
neorrhaphy with  a  suspension  of  the  uterus  to  correct  the  sag.  The 
result  has  been  that  the  patient  has  gained  in  weight,  is  free  from 
bladder  irritation,  and,  unless  excessively  tired,  the  frequency  of 
voiding  is  normal. 

The  confirmation  of  the  diagnosis  of  a  case  of  this  character 
must  depend  mainly  on  the  bacteriological  examination  and  the 
finding  of  residual  urine.  The  cystoscope  shows  a  bladder  con- 
gested and  sagging.  The  chemical  and  microscopical  examinations 
of  the  urine  are  of  only  relative  importance,  for  the  elements  of 
pus  and  albumin  upon  which  the  usual  dependence  is  placed  in  the 
diagnosis  of  bladder  inflammations  are  very  variable  constituents 
— sometimes  in  marked  abundance,  sometimes  very  scant. 

For  the  bacteriological  examination  it  is  necessary  to  have  a 
catheterized  specimen.  This  is  preferably  obtained  by  means  of  a 
glass  catheter  with  a  rubber  cuff  protecting  the  end,  taken  directly 
from  the  lysol  solution  in  which  it  was  placed  after  boiling  and  in- 
troduced without  other  lubrication  into  the  urethra  after  the  orifice 
has  been  thoroughly  washed  off  with  a  sterile  antiseptic  solution. 
The  first  portion  of  the  urine  is  discarded,  and  then  the  flow  is 
directed  into  a  sterile  bottle.  The  bladder  is  not  completely  emp- 
tied, for  thus,  I  believe,  we  obtain  a  more  uniform  sample. 

Though  Kelly,  of  Baltimore,  advises  the  removal  of  the  rubber 
cuff  before  collecting  the  specimen,  this  is  not  necessary.  If  left 
attached  and  the  end  untouched,  it  is  useful  for  directing  flow  into 
the  sterile  bottle.  It  is  important  that  the  patient  take  no  urinary 
antiseptics  for  twelve  hours  preceding  the  catheterization. 

Lately  the  current  literature  has  been  belittling  the  value  of  the 
hexamethylenamine  preparations  as  antiseptics,  and  even  such  au- 
thorities as  those  from  the  Rochester  clinics  have  decided  that  the 
antiseptic  value  was  nil.  It  is  true  that  individuals  do  not  break  up 
the  drug  in  the  body  in  the  same  degree,  so  the  quantity  of  formal- 
dehyde liberated  varies.  Thus,  in  some  cases,  large  doses  are  neces- 
sary, in  order  to  obtain  free  formaldehyde.  Individuals  naturally 
vary  in  susceptibility,  and  kidney  irritation  is  not  uncommon  even 


IJLADDKIJ   INFECTIONS  169 

witli  small  doses.  These  two  ohjectioiis,  liowevef,  ai-e  not  siitticient 
to  justify  discarding'  tlie  dni^'.  Our  experience  in  a  large  number 
of  l)act(Miol()<>ical  examinations  of  the  urine  has  been  that,  unless 
tlie  infection  was  a  very  severe  one,  the  taking  by  the  ])atient  of 
any  of  the  hexamethylenamine  preparations  previous  to  the  ex- 
aminatioii  interfered  witii  tlie  findings.  It  does  not  seem  necessary 
even  to  have  free  formaldehyde  present  in  order  to  ])i()duce  some 
inhibition  of  the  culture. 

The  determination  of  tlie  resi(hial  urine  is  accojnj)lished  ])y  hav- 
ing the  ])atient  urinate  and  then  passing  a  catheter.  In  some  cases 
the  ([uantity  obtained  may  be  only  a  few  drachms,  but  any  consid- 
('ral)k^  quantity  obtainable  after  urination  in  the  normal  manner 
indicates  the  degree  of  sagging,  and  it  is  upon  this  ptosis  that  the 
infection  depends.  The  fact  that  a  nervous  individual  under  ex- 
citement may  secrete  excessive  quantities  of  urine  must  be  remem- 
l)ered,  for  thus  the  findings  will  be  modified.  The  finding  of  residual 
urine  is  of  value  only  when  taken  in  conjunction  with  the  pelvic 
examination. 

As  has  been  mentioned  indirectly  in  the  histories  quoted,  we 
have  in  the  ordinary  hard-rubber  pessary,  where  its  insertion  is 
j)ossil)le,  a  valuable  aid  in  determining  the  prognosis  of  operative 
interference.  In  fact,  it  is  so  good  that  a  number  of  our  patients 
will  accept  the  pessary  as  a  substitute  for  the  operation. 

Without  operative  procedures  to  overcome  the  residual  urine, 
the  prospect  for  a  permanent  cure  is  not  good.  The  type  of  opera- 
tion must  depend  upon  the  condition  and  aim  to  correct  the  incom- 
l)lete  emptying  of  tlie  l)ladder. 

In  urinary-tract  involvement  in  women  it  is  impossible  by  symp- 
toms alone  to  draw  the  line  between  the  pathological  conditions  in 
the  l)ladder  and  those  in  the  kidney  and  ureters.  When  by  chemical 
and  bacteriological  examination  of  the  urine  we  have  proven  that 
an  infection  exists  in  the  urinary  tract,  it  is  then  necessary  to  de- 
cide as  to  the  location  of  that  infection.  The  presence  of  bacteria 
in  the  urine  is  not  alone  sufficient  evidence  of  infection.  If  it  is  pos- 
sil)le  to  exclude  a  systemic  source  as  the  cause  of  the  bacterial 
contamination  of  the  urine,  it  is  fair  to  assume  that  the  germs  have 
their  origin  in  the  urinary  tract.  The  bacteriuria  of  urinary-tract 


170  THE  GYNECOLOGY  OF  OBSTETRICS 

origin  is  not  necessarily  associated  with  symptoms,  though,  as  a 
rule,  their  presence  is  indicative  of  some  pathology  which  gives  its 
own  symptom  complex.  Bladder  contamination,  with  sterile  kidney 
urine,  and  no  pelvic  infection  to  account  for  the  presence  of  bac- 
teria by  direct  extension,  is  suggestive  of  improper  drainage.  The 
bladder  ptosis  may  have  none  of  the  signs  and  symptoms  of  cystitis 
apart  from  the  irritable  bladder.  In  the  absence  of  kidney  infection 
symptoms,  when  the  kidney  urine  shows  contamination,  this  con- 
tamination is  most  frequently  the  result  of  stasis  above  the  blad- 
der. The  most  common  cause  for  such  stasis  is  the  floating,  or  mov- 
able, kidney. 

Severe  kidney  conditions  which  give  bladder  irritation  are  natu- 
rally outside  the  scope  of  this  work,  though  many  such  pathologies 
have  as  their  beginning  the  conditions  under  consideration.  Many 
symptoms  and  findings  of  bladder-urine  stasis  are  also  found  with 
urine  stasis  above  the  bladder,  but  the  movable  kidney  at  the  pres- 
ent time  is  given  ybtj  scant  pathological  consideration. 

As  late  as  September,  1912,  Hedges,  in  a  paper  read  before  the 
American  Gynecological  Society,  wrote  as  follows,  and  to  his  state- 
ments no  exception  was  taken  by  those  present : 

"Reverting  to  the  subject  of  neurasthenia,  just  a  word  about 
floating  kidney.  We  frequently  find  these  two  conditions  in  the 
same  patient  and  used  to  jump  to  the  conclusion  that  the  movable 
kidney  was  the  cause  of  nervousness,  but  fixing  the  kidney  did  not 
cure  the  nerves.  If  in  one  of  these  cases  there  are  severe  paroxysms 
of  pain  due  to  kinking  of  the  ureter  or  pelvis  of  the  kidney,  and 
during  these  attacks  of  pain  or  just  afterward  marked  urinary 
changes  occur,  then  we  are  warranted  in  fastening  the  kidney. 
Morris  has  recently  called  attention  to  the  splint-belly  rigidity  of 
the  muscles  overlying  the  organ  on  the  same  principle  that  the  rec- 
tus protects  an  inflamed  appendix.  It  seems  only  reasonable  that  a 
moderate  amount  of  nephroptosis  should  be  harmless,  just  as  a 
moderate  sagging  of  other  viscera  gives  rise  to  no  unpleasant 
symptoms. ' ' 

Quoting  from  a  personal  communication  from  Dr.  Guy  L.  Huri- 
ner,  of  Johns  Hopkins : 

'^  I  suppose  you  refer  in  your  question  to  the  cases  mentioned  of 
stricture  of  the  ureter.  Of  course,  many  of  my  hydronephrosis 


I J  LADDER  INFECTIONS  171 

cases  j-vrc  due  to  ptosis  of  the  kidney,  tlie  hydronephrosis  develop- 
ing: hecause  of  an  al)en'aiit  vessel,  as  suo-(!,ested  by  Mayo,  or  be- 
cause of  the  i)t()sis  of  tlie  ki(hiey  wliile  tlie  ureter  is  being  hehl  in 
its  original  position  by  the  periureteral  bands  of  the  peritoneum. 
As  to  tlie  bacteriological  findings,  it  is  rather  significant  that  in  my 
cases  of  stricture  of  the  ureter  which  1  credited  to  tonsil  infection 
or  toxemia  the  infection  has  been  by  the  staphylococcus,  unless  the 
urine  was  sterile.  As  you  know,  most  hydronephrosis  kidney  infec- 
tions from  all  causes  are  l)y  the  colon  bacillus." 

Osier  says  far  too  nuich  attention  is  given  to  the  condition  wliich 
is  often  associated  with  neurasthenia. 
Says  Lepine : 

"It  is  incontestable  that  a  displaced  kidney  is  predisposed  to 
the  development  of  nephritis.  Kinking  of  the  ureter  may  cause 
changes  in  the  excretion  of  the  urine,  but  also  stasis  in  the  canalic- 
uli,  which  is  very  favorable  to  the  infection  of  the  kidneys." 

Stiumpell  says : 

"  In  a  great  majority  of  cases  of  floating  kidney,  we  have  to  deal 
with  those  familiar  and  frequent  conditions  of  a  nervous  character 
which  are  termed  h^^steria  or  neurasthenia.  It  is  not  always  advis- 
able to  apprise  the  patient  of  the  fact,  for  with  a  person  of  this 
sort  the  mere  idea  of  possessing  a  '  floating  kidney '  is  enough  to 
stir  up  a  host  of  subjective  symptoms — unless  you  wish  to  use  it 
for  suggestive  therapeutics." 

He  advises  elimination  of  every  possible  pathology  before  credit- 
ing the  floating  kidney  with  importance. 

I  quote  the  following  statements  from  Dieulafoy's  latest  work 
on  medicine : 

"Edebohls,  Box,  and  Newman  have  claimed  to  cure  a  one-sided 
nephritis  by  fixing  a  movable  kidney — cases  where  the  kidney  was 
enlarged,  painful,  and  the  albumin  abundant.  The  movable  kidney 
was  supposed  to  be  exempt  from  lesions  for  a  long  time.  Although 
the  cases  reported  by  Edebohls  do  not  give  all  the  medical  details 
of  the  question,  it  is  none  the  less  true  that  people  with  movable 
kidneys  have  albuminuria.  The  albumin  is  present  in  fourteen  per 
cent,  according  to  Schilling.  The  term  Bright 's  disease  implies  the 
idea  of  bilateral  nephritis.  The  presence  of  albumin  and  casts  in 
the  nrine  is  not  sufficient  to  prompt  the  diagnosis  of  Bright 's  dis- 


172      THE  GYNECOLOGY  OF  OBSTETRICS 

ease.  This  confusion  is  made  by  surgeons.  It  may  falsify  our  ideas. 
I  am  of  the  opinion  that  in  some  of  the  published  cases,  neverthe- 
less, it  does  seem  that  tuberculosis  was  not  present  and  that  they 
were  really  cases  of  chronic  unilateral  nephritis  Avithout  pain  and 
hematuria.  It  is  certain  that  results  of  surgical  intervention  are 
often  excellent  in  unilateral  acute  or  chronic  nephritis,  but  it  is  in- 
dispensable to  state  clearly  the  indications  and  contraindications 
and  select  cases  amenable  to  operation.  For  the  time  being,  we  are 
unable  to  ansAver  this  question  because  many  of  the  published  ac- 
comits  are  incomplete  from  a  medical  point  of  view.  I  am  con- 
Adnced,  however,  that  this  gap  will  soon  be  filled. " 

The  consensus  of  opinion  seems  to  be  that  the  movable  kidney  is 
very  common,  and  ma}^  occasionally  be  associated  with  diverse 
morbid  conditions  without  causing  original  symptoms.  But  a  diag- 
nosis of  movable  kidney  is  very  questionable  unless  the  kidney  is 
definitely  giving  trouble  by  pain,  hematuria,  and  abdominal  tumor, 
with  possibly  gastralgia,  nausea,  and  vomiting,  and  occasionally 
an  intermittent  hydronephrosis. 

All  writers  acknowledge  the  coincident  occurrence  of  mental  and 
nervous  disorders  and  movable  kidney,  but  none  see  any  signifi- 
cance in  the  fact  or  offer  any  explanation.  Alienist  writers  have 
frequently  demonstrated  the  variations  in  blood  pressure  that  are 
so  often  coincident  mth  the  aggravations  of  mental  disorders,  and 
are  inclined  to  look  upon  toxemia  as  a  cause,  and  that  probably  of 
intestinal  origin.  A  clinical  study  of  the  urine  in  cases  with  mov- 
able kidney  in  connection  with  this  blood-pressure  investigation 
should  be  of  interest. 

By  the  presentation  of  some  clinical  cases  I  can  best  summarize 
the  results  of  my  study  of  the  bacteriology  of  the  urine  with  spe- 
cial reference  to  movable  kidney. 

Miss  C,  aged  24,  complains  of  severe  pain  at  menstruation,  re- 
lieved when  flow  commences.  Has  some  pain  after  urination,  and 
occasionally  has  to  void  frequently.  A^Hien  seated  vulva  is  sensitive. 
Has  been  treated  in  the  East,  Examination  shows  introitus  normal 
excexDt  for  eroded  area  external  to  f  ourchette.  Uterus  slightly  retro- 
verted,  mth  cervix  flexed  on  body  so  that  os  and  fundus  are  in  line ; 
OS  very  small.  Appendages  on  left  side  thickened.  Right  kidney  low, 
tender,  enlarged;  tenderness  along  course  of  both  ureters.  Ex- 
amination of  urine  gives  trace  of  albumin.  Specific  gravity  1.020 


BLADDER  INFECTIONS  173 

witli  sonic  cell  detritus,  and  on  culture  the  stap?iylocoecus  alba. 
Cystoscopc  shows  bladder  normal  except  for  some  congestion  at 
orifice  of  ri<Aiit  iiretei-.  Catheteiization  of  ureters  gave  twice  the 
quantity  of  urine  from  the  right  side  with  a  specific  gravity  of 
l.OOf!;  tiace  of  all)umin  ;  occasional  leucocytes,  but  no  casts.  Animal 
inoculation  of  s(^i)aiated  urines  gave  no  results.  X-ray  pictures 
were  negative.  Vaccines  and  systemic  treatment  gave  some  help, 
but  did  not  cure,  although  for  weeks  at  a  time  urine  would  be  nor- 
nuil.  A  thorougli  dilatatifui  of  the  cervical  canal  done  previously  to 
the  investigation  of  tlie  kidneys  cleared  up  the  menstrual  pain. 

Miss  AL,  aged  30,  complained  of  backache  dating  from  fall  two 
years  ago.  Plad  a  definite  Dietl's  crisis  in  October,  1911,  followed 
by  suppression  of  urine  and  a  temperature  of  103"  with  uremic 
symptoms.  Had  a  pulmonary  tuberculosis  some  years  ago.  Exami- 
nation shows  practically  normal,  though  somewhat  undeveloped, 
pelvic  organs.  Abdomen  has  scar  from  an  appendectomy  done  six 
years  ago,  at  which  time  there  was  no  kidney  condition.  Abdomi- 
nal palpation  presents  a  very  tender,  somewhat  enlarged  low-down 
right  kicbiey,  left  kidney  not  palpable.  Investigation  of  urinary 
tract  shows  a  normal  bladder  with  a  depressed  opening  of  right 
ureter.  The  urine  from  the  right  kidney  showed  125  c.c.  in  an  hour, 
and  returned  fifteen  per  cent  phenol  sulpho^jhthalein ;  was  clear  in 
color  and  excreted  in  continuous  drops.  The  left  urine  totaled  110 
c.c,  and  gave  also  fifteen  per  cent  coloring  matter.  The  microscopi- 
cal examination  showed  a  few  white  blood  cells  and  some  granular 
debris,  with  the  greater  quantity  on  the  left  side.  A  trace  of  albu- 
min was  present  in  the  right  urine.  Bacteriological  examination  of 
the  right  urine  showed  a  streptococcus  and  a  large  bacillus ;  of  the 
left  the  large  bacillus  alone.  The  guinea-pig  inoculation  showed  no 
tuberculosis.  There  was  no  evidence  of  stricture  or  hydronephrosis. 

This  patient  has  been  cured  of  her  backache  and  bladder  s>Tiip- 
toms  by  Long-year's  operation  on  the  nephrocolic  ligament  com- 
bined with  fixation  of  the  capsule.  Concurrently  with  the  improved 
symptoms,  the  bacterial  count  in  the  urine  rapidly  diminished,  un- 
til now  a  practically  sterile  urine  exists  A\ith  only  twenty-eight  bac- 
teria to  the  cubic  centimeter,  compared  Avith  the  uncountable  num- 
ber preoperatively. 

Miss  B.,  aged  25,  has  been  in  many  physicians'  hands  with  vary- 
ing diagnoses,  with  conformity  by  only  two  on  a  tuberculosis  of 
the  right  kidney.  She  is  better  now  than  for  some  years,  but  suffers 
from  severe  backache.  About  once  in  six  months  she  has  an  attack 
of  pain  in  abdomen  and  diarrhea  with  much  fresh  blood.  She  had 


174  THE  GYNECOLOGY  OF  OBSTETRICS 

a  hip  trouble  fifteen  years  ago.  She  states  that  in  1908  tubercle 
bacilli  were  found  in  the  urine,  and  improvement  followed  tuber- 
culin. Examination  shows  an  enlarged,  tender  movable  kidney  low 
down;  no  ptosis  of  the  left.  The  cystoscope  shows  no  bladder  ab- 
normality. The  quantity  of  urine  from  each  kidney  is  practically 
the  same,  but  the  right  shows  more  normal  character  of  flow.  The 
phenol  sulphophthalein  shows  up  in  four  minutes  from  right  side 
and  in  four  and  a  half  from  the  left.  The  proportional  elimination 
is  the  same  with  a  total  return  of  sixty  per  cent  in  two  hours.  The 
urine  from  the  left  kidney  gives  twice  as  much  urea ;  both  show  a 
trace  of  albumin  and  some  blood  cells,  but  no  casts.  Bacteriological 
examination  of  bladder  urine  gives  an  uncountable  number  of  a 
streptococcus  and  a  staphylococcus.  With  guinea-pig  inoculation 
the  urine  of  both  right  and  left  kidne3^s  shows  a  negative  finding. 
This  patient  improved  with  urinary  antiseptics  and  a  corset,  and 
six  months  later  submitted  to  operation.  Four  months  after  oper- 
ation all  the  symptoms  had  subsided,  and  there  were  less  than  a 
hundred  staphylococci  to  the  cubic  centimeter  of  urine,  the  strepto- 
cocci having  disappeared.  Two  months  later,  with  still  no  medicinal 
treatment,  the  urine  contains  only  twenty-eight  staphylococci  to 
each  cubic  centimeter. 

In  these  three  cases  I  infer  that  we  have  the  "  unilateral  nephri- 
tis "  of  Dieulafoy.  He  believes  that  many  are  due  to  tuberculosis. 
I  would  go  a  step  further  and  add  that  all  of  them  are  germ  condi- 
tions. They  are  in  no  sense  a  '' Bright 's  disease,"  but  are  second- 
ary to  a  displaced  kidney  interfered  with  in  function.  And  I  believe 
that  in  the  bacteriological  examination  we  have  our  data  for  the 
exact  medical  classification  he  desired.  In  neither  case  was  the 
urine  from  the  normal  kidney  free  from  growth,  but  this  growth 
was  always  less  pathogenic,  and  with  its  germs  so  few  in  number 
that  for  all  practical  purposes  the  urine  was  considered  sterile. 
The  unimpaired  function  showed  that  a  Bright 's  disease  did  not 
exist. 

I  have  shown,  I  think,  that  we  cannot  cure  these  cases  without 
support,  and  I  believe  operation  is  indicated.  These  cases  are  the 
type  of  movable  kidney  that  one  can  not  overlook,  on  account  of  the 
local  symptoms ;  but  the  following  cases  I  have  selected  to  show 
that  before  that  stage  is  reached  the  movable  kidney  is  giving 
trouble  and  is  gradually  developing  into  the  gross  type : 


in. ADDER  1NFF.CTI0NS  175 

j\l  |-s.  D.,  ai;(Ml  ,')(),  has  had  one  chihl,  hoi'ii  in  a  (liriiciilt  la])()r. 
Three  years  a^'o  she  had  a  <>()()(l  sur<i,'e()]i  con-cct  the  pelvic  pathol- 
ogy. Her  ])i'eseiit  ('oinplaint  is  backache  and  ])airi  in  the  i-ight  side 
and  a  l)ladd('r  which  voids  excessively  when  she  is  tired.  Kxaiiii- 
natioH  shows  a  fairly. normal  i)elvis  and  good  resnlts  fi-oni  the  i)las- 
tic  work.  She  has  a  low,  tender  right  kidney  and  tenderness  at  ]\lc- 
Burney's  [)()int — a  frecpient  concomitant  of  movable  ki(biey,  and 
not  always  indicative  of  appendix  inflammation  in  these  cases.  The 
urine  gives  a  growth  of  a  stapliylococcus  in  large  numbers  with  a 
few  streptococci.  A  corset  has  stopped  the  backache  and  sideache, 
which  was  partially  due  to  a  tender  sacroiliac  joint  and  partially 
to  the  kidney  ])tosis,  and  now  the  urine  is  practically  sterile. 

Mrs.  11.  B.,  aged  40,  complains  of  attacks  of  weakness  in  the  left 
side  and  sometimes  when  the  bowels  move.  These  came  on  after 
helping  her  neighbors  move  a  heavy  table.  I  corrected  some  pelvic 
pathology  seven  years  ago.  Following  these  weak  feelings,  the 
quantity  of  urine  is  increased,  and  the  frequency  of  voiding  great- 
er. The  patient  has  a  low,  tender  movable  left  kidney.  The  urine 
gives  an  uncountable  number  of  staphylococci.  The  patient  is  too 
thin  to  have  a  corset  fitted  perfectly,  but  the  best  we  can  do  has 
improved  her  much  and  the  urine  has  become  sterile. 

Mrs.  E.  B.,  aged  27 ;  no  pregnancies ;  operated  for  retroclisplace- 
ment  by  one  of  our  best  surgeons  three  years  ago,  but  still  con- 
tinues to  be  weak,  nervous,  nauseated,  and  subject  to  headaches, 
with  pain  in  bladder  after  urination.  The  bladder  has  been  abused 
by  the  stitching  of  the  uterus  to  the  anterior  abdominal  wall ;  other- 
wise the  pelvis  is  normal.  The  right  kidney  is  movable  and  tender ; 
the  left  less  so.  There  is  no  enteroptosis.  The  urine  gives  an  un- 
countable number  of  staphylococci  to  each  cubic  centimeter.  The 
patient  improved  with  her  corset  and  the  medical  treatment;  but 
on  developing  kidney  crises  an  operation  was  done.  All  s^miptoms 
have  disappeared,  and  examination  of  the  urine  gives  a  bacteri- 
ological count  of  fourteen  germs  to  the  cubic  centimeter. 

During  nine  months'  observation  of  this  patient,  it  was  found 
impossible  to  obtain  kidney  support  with  corsets,  and  many  bac- 
teriological examinations  of  the  urine  gave  germs  varying  from  a 
few  hundred  to  the  cubic  centimeter  in  her  best  weeks  to  uncount- 
able numbers  at  times  of  symptom  exaggeration.  The  operation 
showed  a  small  soft  kidney  without  scars.  The  organ  was  held  by 
the  suture  of  a  well-defined  nephrocolic  ligament  and  capsule  fix- 
ation. The  bacterial  count  of  the  urine  has  decreased  to  what  I 
consider  normal. 


176      THE  GYNECOLOGY  OF  OBSTETRICS 

Mrs.  P.,  aged  31,  referred  on  account  of  a  badly  lacerated  cervix, 
has  worn  a  kidney  belt  the  last  year  to  correct  a  right-kidney  ptosis 
which  supposedly  came  from  a  bad  fall.  After  the  correction  of  the 
cervical  condition,  a  corset  was  advised  in  place  of  the  belt,  which 
had  aggravated  the  pelvic  pathology.  The  right  kidney  was  easily 
palpable ;  the  left  less  so ;  bnt  neither  tender.  Two  bacteriological 
examinations  of  the  nrine  at  two  months'  interval  gave  sterile  re- 
sults. A  month  ago,  or  six  months  after  corset  was  first  fitted,  the 
patient  returned  complaining  of  some  dragging-down  feeling  in 
the  right  side.  It  was  found  that  the  corset  had  stretched  sufficient- 
ly to  alloAv  the  kidney  to  remain  lower  than  normal.  The  organ  was 
tender  and  the  urine  culture  gave  a  streptococcus  and  staph^dococ- 
cus  albus,  about  250  to  each  cubic  centimeter. 

Mrs.  N.,  aged  24;  never  pregnant;  complains  of  backache  and 
bladder  irritation,  general  weakness  and  painful  menstruations. 
Has  been  through  several  minor  and  major  operations ;  is  now 
wearing  a  stem  pessary  to  correct  a  supposed  stenosis.  Pelvis  con- 
siderably congested,  probably  accounting  for  the  bladder  irrita- 
tion, as  urine  examination  chemically  and  bacteriologically  is  nega- 
tive. Right  kidney  movable,  slightly  tender.  Bacteriological  exami- 
nation of  the  urine  in  October  and  December  negative.  The  pelvic 
congestion,  painful  menstruation,  and  bladder  irritation  have 
cleared  uj)  with  local  treatment  and  discarding  of  the  pessary.  In 
March,  she  came  complaining  of  weight  and  drag  in  right  side. 
Examination  showed  poorly  fitting  corset  and  staphylococcic  in- 
fection of  urine.  A  new  corset  corrected  the  symptoms,  and  now, 
three  weeks  later,  the  urine  is  sterile. 

These  cases  are  typical  examples  of  a  large  class  of  patients  in 
whom  there  is  a  movable  kidne}^  that  is  the  cause  of  the  trouble,  but 
this  pathology  is  overlooked  unless  it  is  associated  with  a  Dietl's 
crisis.  Many  of  them  have  been  operated  upon  for  pelvic  iDathology, 
without  complete  relief. 

I  realize  that  it  is  too  early  to  make  au}^  too  positive  claims  for 
the  diagnostic  value  of  the  culture  in  urinary-tract  stasis,  but  the 
findings  show  that  in  every  case  in  which  the  condition  can  be  con- 
sidered pathological  Ave  have  bacteriological  evidence  in  the  urine, 
except  in  some  cases  of  kidney  ptosis  which  give  the  acute  crises. 

It  may  be  well  asked  why  so  many  displaced  kidneys  give  no 
SA^mptoms.  I  believe  that  in  every  displaced  kidney  is  a  latent  possi- 
bility of  trouble,  but  as  long  as  the  individual  is  in  good  physical 


I^,LAI)I)KIJ   INFECTIONS  177 

coiiditioii,  the  pci-istnltic  action  oF  the  kidney  pch'is  and  ureter  is 
maintained,  and  this  prevents  urine  stasis.  This  peristaltic  action 
is  of  vast  iinportatice  in  pi-evontin^'  tlie  posture  of  the  patient  fi'oni 
interferin<i,'  with  the  ki(hiey  function. 

In  the  catheterization  of  the  ureters  of  such  kidneys  as  are  de- 
scrihed  in  the  three  cases  of  tlie  so-called  "unilateral  nei)hritis  " 
quoted,  there  is  an  absence  of  the  rhythmic  action  of  the  muscles, 
so  that  the  urine  leaves  the  catheter  from  the  affected  side  in  con- 
tinuous drops.  Some  urologists  state  that  this  is  a  sign  that  the 
catheter  has  reached  the  pelvis  of  the  kidney.  In  the  norjnal  indi- 
vidual this  may  be  so,  but  a  patient  with  urine  stasis  above  the 
bladder  shows  the  same  sign  even  when  the  catheter  is  inserted 
only  a  short  distance.  In  such  cases  it  indicates  either  a  dilated 
pelvis  and  ureter  or  the  loss  of  the  normal  peristaltic  action. 

In  any  kidney-sag  it  is  only  a  question  of  time  when  the  over- 
worked muscles  will  stretch,  as  does  a  labored  heart,  and  thus  per- 
mit stasis  of  the  urine.  The  consequent  alteration  of  the  chemistry 
of  the  urine  permits  the  growth  of  certain  germs  entering  from 
the  neighboring  organs  or  from  the  blood  stream.  Whatever  con- 
gestion results  will  add  to  the  handicap  under  which  the  organ 
works.  It  is  not  a  question  so  much  as  to  the  kind  of  germ  present 
as  it  is  the  absence  of  sterile  urine  which  is  of  significance  in  mov- 
able kidney. 

Continued  investigation  of  the  urine  from  the  bacteriological 
side  has  convinced  me  that  more  accurate  and  valuable  data  are  ob- 
tainable from  a  count  of  the  number  of  germs  to  each  cubic  centi- 
meter of  urine,  and  for  this  suggestion  I  am  indebted  to  Dr.  Archi- 
bald. 

We  feel  that  we  are  justified  in  considering  a  urine  containing 
only  a  few  germs  per  cubic  centimeter  a  normal  so-called  sterile 
urine.  In  all  cases  truly  pathological  the  count  will  run  from  a  few 
hundred  to  an  uncountable  number,  depending  on  the  severity  of 
the  pathology.  Frequently  more  than  one  variety  of  bacteria  is 
present,  though  if  one  predominates  it  may,  by  its  development  re- 
action in  the  culture  medium,  destroy  the  other  growths.  Naturally, 
this  has  to  be  borne  in  mind  in  checking  up  the  findings  and  in  pre- 
paring vaccines.  It  will  also  emphasize  the  necessity  for  autoge- 


178  THE  GYNECOLOGY  OF  OBSTETRICS 

nous  vaccines  and  may  account  for  imperfect  results  from  these 
agents. 

The  operative  treatment  of  kidney-sag  has  been  considered  in- 
directly in  connection  with  the  histories  quoted,  and  since  it  is 
hardly  within  the  range  of  this  monograph  it  will  not  be  considered 
in  detail. 

I  have  shown  the  necessity  for  correcting  bladder-sag  in  order  to 
cure  a  cystitis.  The  principles  involved  in  kidne}^  ptosis  are  analo- 
gous. We  have  a  certain  amount  of  stasis ;  and  with  this  stasis  the 
urine  is  altered  and  loses  its  claimed  antiseptic  action.  If  a  pyelitis 
develop  through  the  entrance  of  pus-forming  germs,  the  giving  of 
drainage  is  of  prime  importance  in  treatment,  and  not  until  that  is 
accomplished  can  we  expect  results  from  vaccines. 

The  best  method  of  correcting  the  ptosis  is  a  debatable  question 
at  present.  We  have  swung  strongly  from  the  kidney  fixation, large- 
ly, I  believe,  because  too  many  tried  to  cure  movable  kidneys  associ- 
ated with  enteroptosis  in  that  way.  The  cases  not  being  segregated, 
many  a  movable  kidney  was  corrected  when  the  pathology  from 
which  the  patient  suffered  was  situated  elsewhere.  Again,  many 
cases  recurred  and  were  accounted  for  by  one  of  two  causes :  first, 
those  enteroptotic  cases  where  kidney  fixation  without  support  of 
the  other  organs  could  never  be  expected  to  stay ;  second,  the  neg- 
lect of  the  abdominal  support  so  necessary  to  use  until  the  kidney 
has  had  time  to  ref  oriu  its  own  bed.  If  the  patient  can  be  fitted  with 
a  proper  front-lacing  corset,  we  have,  with  that,  the  means  of  test- 
ing out  our  diagnosis  as  with  a  pessary  in  bladder  ptosis ;  but  that, 
of  course,  is  only  a  palliative  method.  Against  the  regular  kidney 
belt  I  wish  to  enter  a  protest,  for  no  other  abdominal  contrivance 
has  such  a  power  for  evil  in  developing  congestion  in  the  pelvic 
organs.  In  a  thin  individual  I  have  seen  the  two-part  surgical  cor- 
set produce  kidney  crises  by  pinching  the  ureter,  and  in  that  type 
of  individual  the  hope  of  fitting  any  kind  of  a  support  is  rather  for- 
lorn. After  operation  the  abnormal  posture  of  these  individuals 
should  be  overcome  by  a  corrective  corset  properl}^  fitted. 

From  the  standpoint  of  my  clinical  findings,  summing  up  the 
question  of  bacteriology  of  the  urine,  I  believe  that  under  normal 
conditions  of  body  functions  the  urine  is  practically  free  from  bac- 


BLATTDKR   IXFEC'PTOXS  179 

toria;  but  with  any  yystoiiiic  <;('iin  iiifcctioii  tlic  al)ii()niial  a<!,-onts 
arc  ill  a  lar.^c  (l(',i>r('e  eliminated  from  tlic  Ixxly  by  tlio  ki<hiey.s. 
Tliese  i>erms  in  a  miliary  tract  with  iioniial  (lrainajj,e  have  little 
ciiaiice  to  |»i()(hi('('  abnormal  s)!ii|)tonis,  since  tiie  noriiial  rapid 
elimination  and  the  germicidal  action  of  the  urine  prevent  develop- 
ment. To  all  intents,  they  can  be  looked  upon  as  of  no  pathological 
significance,  unless  through  the  great  virulence  of  the  infection  and 
the  patient's  poor  resistance  they  form  i)art  of  a  general  septi- 
cemia. If,  however,  in  the  course  of  tlie  uriiiai'y  tract  there  is  an 
interference  to  the  normal  escape  (so  that  an  actual  or  relative  re- 
tention occurs),  the  urine  itself  so  changes  its  chemical  character 
as  to  afford  a  favorable  culture  medium.  Whether  this  is  due  to  the 
destruction  of  the  ferment  or  to  the  presence  of  altered  chemical 
salts  is  problematic  at  present.  AVe  know,  however,  that  urine  heat- 
ed a  few  degrees  over  bod}^  temperature  or  let  stand  for  a  few^ 
hours  outside  the  body  serves  as  a  good  culture  medium,  and  as 
such  was  used  by  Pasteur  in  the  early  days  of  bacteriology. 

In  typhoid  fever  and  in  other  diseases  in  which  the  germs  are 
present  in  the  blood  stream  we  find  them  recoverable  from  the 
urine,  and  yet  without  attendant  symptoms  of  urinary  tract  infec- 
tion. Experimental  intravenous  injections  of  cultures  have  shown 
that  germs  can  be  demonstrated  in  the  urine  within  fifteen  min- 
utes. These  facts  justify  us  in  assigning  a  germ-excreting  function 
to  the  kidney  and  show  the  necessity  of  some  associated  pathology 
for  the  production  of  a  urosepsis. 

Xot  only  in  bladder  ptosis,  but  also  in  that  of  the  kidney,  we  can 
prove  by  temporary  support  that  the  urosepsis  is  dependent  there- 
on, and  operative  correction  properly  done  emphasizes  the  fact. 

The  very  fact  that  seldom  in  our  examinations  of  urine  do  we 
find  onl3^  one  germ  present  makes  more  probable  the  autogenous 
theory  of  infection.  Consequently,  this  prevents  any  conclusions  of 
value  being  deduced  from  the  character  of  germ  present  outside 
of  the  self-evident  fact  that  the  severity  of  the  symptoms  will  de- 
pend on  the  characteristics  of  the  germ.  Yet  even  active  strepto- 
cocci are  frequently  present  without  producing  symptoms  when  no 
stasis  complicates  the  urine  discharge. 

Like  many  other  observers,  I  have  found  that  in  cases  of  uro- 


180      THE  GYNECOLOGY  OF  OBSTETRICS 

sepsis  in  which  the  bacillus  coli  communis  is  present  it  is  almost 
impossible  to  eradicate  the  germ  completely,  though  the  patient  to 
all  intents  has  been  cured. 

Some  bacteriologists  believe  this  continuance  of  the  colon  bac- 
teriuria  is  due  to  the  low  type  of  the  organism  and  the  character  of 
the  mucous  membranes  of  the  bladder,  rather  than  to  the  fact  that 
the  colon  is  naturally  a  habitant  of  the  body  and  proof  against  its 
defenses. 


.  KIDNEY  PTOSIS 

AS'1'^1)^'  of  sixty-five  eases  of  movable  kidney  (made  with 
special  reference  to  tlie  l)acterioloj>;ical  aspect)  has  pro- 
duced data  of  considerable  interest.  In  these  cases  I  do 
-  not  include  those  ])atients  with  general  enteroptosis;  nor 
are  those  with  acute  infection,  the  pus  kidney,  or  the  tuberculous 
infection  considered. 

The  acute  kidney  infections  are  mostly  associated  with  general 
systemic  involvements.  If  the  virulence  is  great  or  the  patient's  re- 
sistance poor,  the  breaking  down  of  the  parenchyma  occurs  and 
tlie  "pus"  kidney  develops.  Otherwise,  the  process  subsides,  re- 
sponding more  or  less  promptly  to  therapeutic  measures  unless  a 
urine  stasis  exists.  If  there  is  any  interference  with  the  urine  es- 
cape, the  inclination  to  chronicity  is  present,  and  the  pathology 
becomes  resistant  to  medication. 

Patients  with  general  enteroptosis  are  excluded  from  this  study 
because  there  are  in  their  pathology  so  many  other  factors  that 
must  be  considered  as  likely  to  complicate  the  findings. 

As  has  been  seen,  the  simple  presence  of  bacteria  in  the  urine  is 
not  diagnostic  of  urogenital-tract  infection.  For,  though  the  con- 
sensus of  opinion  is  that  urine  in  normal  individuals  is  free  from 
germs,  some  observers  report  a  considerable  percentage  of  pre- 
sumably healthy  individuals  whose  urine  contained  bacteria.  Many 
individuals  with  no  urinary  symptoms  may  have  the  urine  loaded 
with  germs.  Any  germ  free  in  tlie  blood  stream  makes  its  appear- 
ance in  the  urine  after  a  short  interval  of  time.  Thus  germs  intro- 
duced through  intravenous  injections  of  cultures  are  recoverable 
from  the  urine,  and  in  systemic  diseases  such  as  typhoid  the  bac- 
teria are  also  found. 

The  urine  has  germicidal  power,  as  shown  by  the  decrease  in  the 
number  of  bacteria  during  the  first  few  hours  after  voiding,  but 
this  action  is  not  marked,  and  is  readily  destroyed  by  slight  modi- 
fication, such  as  comes  from  exposure  to  air  or  moderate  degrees 


182      THE  GYNECOLOGY  OF  OBSTETRICS 

of  heat.  The  urine  from  an  infected  bladder  and  kidney  has  al- 
ready lost  its  germicidal  power  through  chemical  changes  previous 
to  voiding,  so  that  after  expulsion  the  increase  of  the  number  of 
germs  is  rapid.  In  order  to  avoid  too  great  a  variation  from  such  a 
cause,  the  quantitative  determinations  have  been  made  as  early  as 
possible  after  catheterization.  However,  for  clinical  purposes  the 
variation  in  twelve  hours  is  not  of  great  consequence. 

The  frequency  of  the  occurrence  of  bacterial  contaminated  urine 
must  justif}^  the  conclusion  that  associated  with  bacteriuria  there 
is  present  a  predisposing  factor  that  determines  the  production  of 
kidney  infection.  With  this  factor  in  mind,  a  study  of  the  bacteri- 
ology of  the  urine  in  movable  kidneys  was  undertaken.  A  necessity 
for  a  classification  of  the  varieties  of  kidney  ptosis  early  became 
evident;  and  to  meet  that  need  the  cases  were  divided  into  four 
groups,  using  the  clinical  and  bacteriological  symptoms  as  a  basis. 

The  first  group  consists  of  the  cases  of  so-called  "unilateral 
nephritis."  Here  a  usually  right-sided  involvement  is  found.  The 
kidney  is  low,  easily  palpable,  tender  to  the  touch,  and  somewhat 
enlarged.  There  is  bladder  irritability,  though  inspection  reveals 
nothing  but  possibly  a  congested  mucous  membrane  with  a  redden- 
ing of  the  right  ureter  orifice.  The  urine  shows  some  albumin  and 
pus,  a  few  casts,  and  numerous  bacteria,  but  these  vary  from  time 
to  time.  The  patient  complains  of  a  dragging  feeling  with  dull  pain 
in  the  right  lumbar  and  hypochondriac  regions.  These  cases  sel- 
dom exhibit  Dietl's  crises,  but  are  often  associated  with  periodical 
uremic  attacks  evidenced  by  headache,  fever,  puffiness  of  the  face, 
and  lessening  of  the  urine  output. 

As  has  been  stated,  the  classification  of  this  pathology  as  a  "uni- 
lateral nephritis  "  is  not  technically  correct,  for  the  term  "nephri- 
tis "  is  too  intimately  associated  with  Bright 's  disease  to  convey 
any  other  impression.  Such  cases  are  invariably  germ  involve- 
ments of  the  kidney  pelvis,  and  what  changes  take  place  in  the  kid- 
ney parenchyma  are  wholly  secondary  to  the  infection. 

The  patients  exhibiting  definite  Dietl's  crises  come  into  the  sec- 
ond division.  The  attack  of  pain  known  as  a  crisis  most  frequently 
comes  if  the  patient  suddenly  assumes  the  standing  posture.  The 
pain  is  accompanied  by  faintness  and  occasionally  a  variation  in 


KIDNKV   I^TOSIS  183 

urine  secretion,  not  only  as  to  (juantity,  hnt  also  in  clieinical  and 
iniei-oscopical  Undiniis.  The  symptoms  are  relieved  l)y  the  recuni- 
Ix'iit  posture,  and  the  attack  may  he  followed  hy  a  tenderness  of 
the  kidney,  i)ersistin,<;'  foi-  a  few  houis.  Diiriiii;'  the  interval  hetween 
attacks  the  mine  nia\'  e.\lii!)it  ahsolutely  no  ahnoi-mal  chang'es. 

Occasionally  one  sees  cases  that  nmst  come  under  this  head  even 
thouii,!)  no  i)ain  is  conii)lained  of,  where  a  sudden  faintin*>'  is  the 
piimary  symptom.  It  may  be  that  these  patients  are  extremely  sns- 
ceptihle  to  pain,  and  that  the  complete  nnconseionsness  is  the  re- 
sult of  tile  pain  stinudus,  Init  that  symptom  is  fori^otten.  The  sug- 
gestion of  Dr.  R.  A.  Archibald  that  anaphylaxis  may  enter  largely 
into  this  type  of  attack  is  of  interest.  Anaphylaxis  (or  allergy,  as 
\^on  Pirquet  terms  it)  depends  on  periodic  proteid  splitting.  The 
absorption  of  these  split  products  gives  rise  to  definite  clinical 
symptoms  peculiar  to  the  type  of  proteid  present,  Init  necessarily 
these  t)eriods  of  abnormality  must  be  separated  by  a  considerable 
interval  of  normal  metabolism.  It  is  reasonable  to  suppose  that,  in 
a  patient  with  free  urine  drainage  that  suddenly  becomes  dis- 
turl)ed,  the  chemical  changes  taking  place  can  readily  cause  marked 
disturbance.  The  two  patients  that  I  have  seen  with  this  type  of 
attack  have  had  more  marked  urine  changes  and  more  prolonged 
uremic  symptoms  than  those  patients  with  classical  crises.  Since 
the  ptosis  was  corrected,  these  patients  have  had  no  recurrence  of 
their  fainting  spells. 

These  two  groups  are  well-recognized  pathological  entities.  Un- 
der the  third  group  should  come  the  cases  that  might  be  said  to  be 
of  questionable  etiological  importance.  It  is  to  this  class  of  cases 
that  the  already  quoted  criticism  of  Strumpell  and  Osier  apply. 
In  these  cases  the  kidney  is  readily  palpable,  the  left  almost  as  fre- 
([uently  as  the  right.  The  organ  may  not  necessarily  be  tender,  and 
usually  is  only  slightly  enlarged.  The  patient  complains  of  side- 
ache  and  some  backache  with  occasional  irritability  of  the  bladder. 
The  nervous  symptoms  are  often  marked  and  of  almost  any  type. 
If  the  right  kidney  is  the  one  at  fault,  digestive  disturbances  are 
present,  due  to  the  close  relation  of  the  cecum  and  kidney.  Upon 
examination  the  bladder  is  usually  found  healthy,  and  the  nrine 
may  show  absolutely  no  changes  except  from  the  bacteriological 


184  THE  GYNECOLOGY  OF  OBSTETRICS 

side.  If,  however,  the  germ  present  is  in  excess,  a  trace  of  albumin 
and  a  few  casts  are  present.  It  is  in  these  patients  that  the  results 
of  the  bacteriological  examination  of  the  urine  are  of  most  signifi- 
cance as  an  aid  to  diagnosis. 

Under  the  fourth  head  are  classified  the  patients  with  kidney 
ptosis  in  whom  no  symptoms  can  be  found  traceable  to  the  con- 
dition and  who  show  on  examination  a  relatively  sterile  urine.  I 
say  ' '  relatively  sterile, ' '  because  only  a  small  per  cent  of  speci- 
mens are  absolutely  free  of  germs.  Out  of  one  hundred  and  twenty- 
five  examinations  made  in  the  type  of  case  under  consideration 
there  were  only  three  specimens  absolutely  sterile. 

In  the  one  hundred  and  twenty-two  examinations  in  which 
growths  were  obtained,  twenty-six  patients,  who  could  not  at  the 
time  be  considered  as  suffering  from  the  effects  of  the  kidney  dis- 
placement, gave  twenty  or  less  colonies  per  cubic  centimeter  in 
thirt^^-two  examinations. 

Of  the  sixty-five  cases  of  kidney  ptosis  investigated,  five  patients 
suffered  with  definite  crises,  two  of  whom  had  marked  uremic  symp- 
toms associated.  In  two  of  these  same  five  cases,  including  one  of 
those  with  uremic  symptoms,  the  urine  had  never  more  than  twenty 
germs  to  the  cubic  centimeter,  even  following  a  marked  attack,  and 
the  urine  was  without  variation  in  the  two  kidneys.  Two  others  of 
these  five  cases  had  more  definite  local  kidney  symptoms,  and  the 
urine  upon  culture  gave  counts  varying  from  two  hundred  and 
ninety-four  germs  per  cubic  centimeter  upward  to  an  uncountable 
number.  After  operation  on  these  tAVO  iDatients  to  correct  the  kid- 
ney displacement,  the  count  dropped  to  below  twenty  per  cubic 
centimeter,  and  has  remained  so  consistently^  for  over  six  months, 
associated  with  general  good  health. 

Four  cases  of  unilateral  nephritis  of  the  right  kidney  have  been 
carefully  investigated.  Two  have  been  cured  by  operation,  and  two 
have  been  improved  by  corsets  and  treatment.  Cystoscopic  exami- 
nation in  each  case  showed  negative  bladder  findings,  except  for 
some  congestion  of  the  orifice  of  the  right  ureter.  The  kidney  func- 
tion was  not  impaired,  though  the  quantity  secreted  by  the  sepa- 
rate kidneys  was  not  equal.  In  three  cases  the  larger  quantity 
came  from  the  abnormal  side,  but  of  decreased  specific  gravity. 


KIDNEY  PTOSIS  185 

On  tliis  side  also  tlici'c  was  no  rliytlnn  to  tlic  discharge.  The  hac- 
t('riolo,i;ical  coniit  (lirfcicd  in  cacli  kidney,  the  number  on  the  right 
side  being  nncountahle.  On  the  left  not  over  four  hundred  ap- 
peared in  any  examination.  Jn  all  cases  there  was  a  mixed  infec- 
tion. Careful  guinea-pig  inoculations  gave  no  evidence  of  tuber- 
culosis. 

The  character  of  any  kidney  infection  will  depend  on  the  pri- 
mary location,  the  type  and  virulence  of  the  germ,  and  the  pa- 
tient's resistance.  A  severe  involvement  in  the  parenchyma  will 
lead  to  abscess  formation  and  kidney  destruction.  Rosenow's  find- 
ings that  the  selective  tendency  of  germs  depends  on  the  type  of 
virulence  may  ])ossibly  account  for  either  a  parenchyma  or  a  kid- 
ney-pelvis involvement. 

My  conclusion  is  that  the  unilateral  nephritis  is  essentially  a 
kidney-pelvis  condition  with  a  certain  amount  of  parenchyma  con- 
gestion as  a  sequela,  for  it  is  devoid  of  the  systemic  and  blood 
signs  of  an  acute  septic  condition.  It  is  invariably  imposed  upon 
a  displaced  kidney,  and  the  condition  promptly  responds  to  oper- 
ative replacement  of  the  organ  that  permits  improved  drainage. 
When  treated  by  corset  support  and  therapeutic  measures,  im- 
provement takes  place,  but  there  is  a  tendency  to  recurrence  of  the 
more  acute  symptoms. 

The  corset  support  promptly  decreases  the  bacterial  count  to  a 
marked  degree,  but  during  its  omission  the  increase  is  again  rapid. 
A  woman  of  sixty-five,  whose  pathology  occurred  following  the 
grippe,  had  on  the  diseased  right  side  an  uncountable  number  of 
germs,  and  on  the  left  side  four  hundred  and  thirty-two  to  the 
cubic  centimeter.  The  corset  correction  reduced  the  count  on  both 
sides  to  less  than  half  the  number.  In  two  other  non-operated  cases 
the  results  were  more  marked. 

In  the  two  cases  operated  upon,  the  bacteria  practically  disap- 
peared from  the  urine  within  a  few  months,  the  decrease  being  uni- 
form and  rapid.  The  symptoms  were  relieved  immediately;  the 
patient  promptly  gained  in  weight,  and  had  no  recurrence  of  the 
uremic  signs. 

An  interesting  feature  in  these  patients  with  unilateral  nephritis 
is  the  presence  of  a  considerable  number  of  bacteria  in  the  urine 


186      THE  GYNECOLOGY  OF  OBSTETRICS 

from  the  supposedl}^  normal  side.  But  the  urine  of  this  side  shows 
a  more  rapid  decrease  in  the  number  of  bacteria  following  surgical 
correction  of  the  abnormal  kidney. 

The  findings  in  the  class  of  cases  listed  as  of  cpestionable  eti- 
ology were  also  w^ell  marked.  The  number  of  bacteria  in  the  urine 
never  reach  the  amount  found  in  the  '^  unilateral  "  type,  but  corset 
correction  always  produced  a  marked  decrease — with  a  prompt  in- 
crease if  omitted.  With  the  lessening  of  the  germ  the  symptoms 
disappeared  to  reoccur  when  the  count  again  increased. 

The  factor  at  fault  is  without  doubt  poor  drainage,  since  the 
urine  through  chemical  changes  becomes  a  suitable  culture  medium 
for  germ  increase.  The  number  of  bacteria  is  relatively  an  indica- 
tion of  the  degree  of  stasis. 

If  we  can  eliminate  the  cases  that  have  a  bacterial  count  de- 
pending upon  a  bladder  involvement  that  is  the  result  of  bladder 
ptosis,  or  upon  jielvic  inflammation,  we  have  an  index  in  a  measure 
of  the  disturbance  the  kidney  ptosis  produces. 

The  type  of  germ  found  seems  to  be  of  little  importance.  The  va- 
rieties will  vary  in  the  same  individual  from  time  to  time,  and,  as 
a  rule,  a  pure  culture  is  seldom  present. 

The  results  obtained  so  far  from  the  bacteriological  examina- 
tions in  these  cases  seem  to  justif}^  the  conclusion  that  urine  con- 
taining a  relatively  small  number  of  germs  may  be  considered  nor- 
mal. In  seemingly  normal  individuals  a  perfectly  sterile  urine  is 
rare,  and  this  must  emphasize  the  fact  that  bacteria  are  being  con- 
stantly eliminated  by  the  kidneys.  Taken  in  conjunction  with  the  ex- 
perimental inoculations  and  the  occurrence  of  germs  in  the  urine  in 
systemic  infections,  it  is  essential  to  acknowledge  a  germ-secreting 
function  to  the  kidney.  This  factor  necessarily  increases  the  im- 
portance of  the  presence  of  a  kidney  ptosis  that  may  interfere  with 
drainage. 

With  the  kidney  ptosis  of  no  matter  what  degree,  the  question 
of  its  bearing  on  the  patient's  health  is  one  of  individual  determi- 
nation. The  amount  of  trouble  from  the  ptosis  depends  more  upon 
the  interference  with  the  urine  flow  and  the  amount  of  stasis  pro- 
duced than  upon  the  particular  location  of  the  organ.  The  stasis 
alone  may  result  in  symptoms  of  a  uremic  character,  but  on  the 


KIDNEY  PTOSIS  187 

kind  of  iiilVctioii  iiii|)()S(Ml  will  (Icpciid  the  (l('<i;ree  of  general  patlio- 
l(),i;i<*al  (lislurhaiic't'.  TIk'  (l('ii,i-('e  of  stasis  and  tlio  amount  of  infec- 
tion ncccssaiv  to  ,i>ive  rise  to  symptoms  essentially  pathologic  de- 
jX'iid  very  lai-gel\'  npoii  the  patient's  sensitiveness  to  defective 
])hysioh)gy. 

If  tile  peristaltic  action  of  the  ki<liiey  pelvis  and  the  ureter  is 
perfect  (uidess  an  acute  ohstruction  occurs,  as  indicated  by  a 
crisis),  the  ptosis  can  be  accepted  as  one  not  requiring  correction, 
])ut  we  must  realize  tliat  in  every  sucli  individual  tlie  foundation 
for  future  ti'onhle  is  present. 


INDEX 


INDEX 


Adhesions  of  opposiiiu'  i-;i\\'  fdm's  in 

plastic  work,  147 
Amputation  of  cervix.  1)0.  !)l 

high.  90 

low.  93,  9-4 

St'hroeder's.  98.  9;") 

Simon's.  98.  95 
Anteflexion  of  uterus.  8 

symj)toms  of.  (i7 

Backache.  102 

Bacterioloo'ieal  examination  of  urine 
Archibald  on.  177 
Brown  on.  163 

Burnett  regarding  sterile.  162 
collection  of  specimens  for.  168 
diagnostic  value  of.  176.  181 
effect  of  corset  upon,  in  kidney 

ptosis.  185 
(xuiteras  on.  168 
Hiss  and  Zinsser  on,  168 
in  infectious  diseases,  168 
in  kidney  ptosis.  183,  184 
influence  of  antiseptics  on.  168 
plate  culture  in,  164 
(piantitative  determinations. 

164.  177 
sterility  in.  162.  168.  179.  180 
types  of  germs  in.  162.  186 
Wood  on  germs  foinid  in.  162 

Bartholin  glands 

as  landmarks.  19.  106 

function  of.  19 

gonorrheal  infection  of.  40.  41. 

150 
gonorrheal  maculae.  40 
location  of.  19 
pathology  of.  19 
structure  of.  19 

Bladder 

cystoscopic  examinations  of.  67 
disturbances  of.  due  to  relaxed 
vaginal  outlet,  103,  144 


]>la(l(l('r — conl  inucd 

intlamnuition   of.   1()4.   Kio    (see 
Ctjslitis) 

irritable.  67.  144 

ptosis  of.   165.   168.   169    (see 
Ffosis  of  bladder) 
Boroglyceride.  71 
Bulbs  of  the  vestibule 

structure  of.  18 

location  of.  18 

Cancer  of  cervix 

Bossi's  theory  of.  46 

carbon-dioxide  freezing  for.  48. 
90 

carcinoma.  45 

early  manifestations.  48 

effect  of  scar  tissue  in  occur- 
rence of,  47 

epithelioma,  45 

involvement  of  Ivmphatics  in. 
49 

methods  of  diagnosis.  49 

operations  for.  48.  90 

radiotherapy  in.  47,  48 

relation  of  to  lacerations.  45.  50 

symptoms  of.  48 

Carbon-dioxide  freezing.  48.  90 

Carunculae  myrtiformes  as  land- 
marks. 110 
Case  history-  of 

abortion    from   cervical   pathol- 
ogy. 159 

bladder  ptosis.  166.  167 

kidney  ptosis.  175 

relaxed  vauinal  outlet.  100.  101. 
141 

sterility    from    cervical    pathol- 
ogy." 160 

unilateral  nephritis.  172,  178, 
174 


192 


THE  GYNECOLOGY  OF  OBSTETRICS 


Cervix 

amputation  of,  90,  93  (see  Am- 
putation of  cervix) 
''arbor  vitae"  in,  6 
blood  supply  of,  8,  9 
canal  of,  4 

cystic  endocervicitis,  57,  155 
definition  of,  3 
ectropion  of,  57,  58,  70 
elongation  of,  26 
gland  secretion  of,  5,  57,  66 
healing  of  injuries  to,  38,  57,  59 
hypertrophy  of,  26 
imanediate  care  of  injuries  of, 

38 
inflammation  of,  53,  59  (see 

Endocervicitis) 
injury  to   adjoining   structures 

in  operation  on,  9 
injuries  to,  37 
lips  of,  3 
lymphatics  of,  10 
'"'Naboth  ovules"  in,  5,  48 
nerves  of,  7 
placing  of  pessary  in  lacerations 

of,  8 
prevention  of  injury  to,  31 
relation  of  to  uterus  and 

vagina,  4 
relation  of  to  bladder  and 

rectum,  9 
repair  of  lacerations  of,  70,  90 

(see  Trachelorrhaphy) 
sensation  of,  7,  8 
structure  and  size  of,  3,  6 
' '  ulcerated  cervix, ' '  57 
Chorioepithelioma 

character  of  growth  of,  51 
location  of,  51 
of  cervix,  51 
of  vagina,  51 
Correct  body  posture,  30 
Corsets 

in  kidney  ptosis,  178,  185 
in  relation  to  posture,  30 
pelvic  congestion  from,  55 

"Crown"  suture,  112,  130 
Crura,  21 


Curettage 

contraindications  to,  151 
dangers  of,  85,  88 
diagnosis  through,  49,  50,  83 
indications  for,  83,  85 
in  malignancy,  50 
instruments  for,  85 
Cystitis 

acute,  164 

chronic,  165 

production  of,  164 

residual  urine  a  factor  in,  165, 

178 
value  of  treatment  in,  165 
Cystocele 

as  hernia,  23 

correction  of,  127,  128,  130  (see 

Repair  of  cystocele) 
denudations  for  correction  of, 

129 
fasciae  in,  10,  24 
in  relation  to  relaxed  outlet,  97, 

117 
mucous  membrane  hypertrophy 

with,  126 
pessary  as  support  for,  63 
production  of,  23,  24,  103,  121, 

123,  125 
residual  urine  in,  162 
theories  of  cause  of,  124,  126 
types  of,  122,  123,  128,  165 
unassociated  with  protrusion, 

165 
with  procidentia,  122,  123,  128 

Diaphragm  (see  Pelvic  diaphragm) 

Dietl's  crisis,  176,  182,  183 

Diptheroid  infections,  41,  42 
treatment  of,  42 

Douches 

medication  in,  72,  73,  135 
method  of  giving,  73 
relaxation  from,  73,  144 
temperature  of,  72,  73,  135,  143 

Drainage  of  uterus 

interference  with,  147,  148,  149 

Drugs  in  gynecology,  70,  71,  72,  73, 
139 


INDEX 


193 


Diidlcv  (»|)('i';i1  ion 

for  stc'i'ilit\'  mid  (hsiuciiorrhea, 

15:3,  ]r)4" 

Dysinciioi-rlH'a 

dilatation  ol'  ccfx'ix  i'or.  l.l-i 
Dndley-Re\n(ilds  (ipcration  for, 

153,"  154 
relief  of,  153 
statistics  of  cure  of.  154,  155 

Ectropion.  58,  70 
Ennn(4  perineorrhaphy    • 

l)u1t('rti\'  denudation.  112 

crown  suture,  112 

incision  and  denudation,  106, 
10!).  112 
Ennnct  trachelorrhaphy 

prevention  of  miscarriage,  157 

steps  of  operation,  90,  91,  92 
(see  Trachelorrhaphy) 
Endoeervicitis 

contraindication  of  stem  pes- 
sary, 156 

cystic.  57.  155 

due  to  remote  pathology,  55 

round-cell  infiltration  in,  53 

symptoms,  54 

treatment  of,  70 
Endometrium 

congestion  of.  56 

glandular  hypertrophy  of,  54 

intiannnation  of,  54.  84 
Episiotomy 

Berkeley  and  Bonne.y  on,  32 

bilateral  incisions.  32 

Hartmann  on,  32 

location  of  incisions,  33 

median  incision,  34,  35 

Peterson  on,  33 

results  on  vaginal  outlet,  33 
Erosion  of  cervix 

effect  of  scar  tissue  on.  62 

healing  of.  61.  70. 

infiannnatory.  60.  61 

types  of,  59!  60,  92 

Floating  kidney 

anaphylaxis  in.  183 
case  hist<n'ies  of.  172.  173.  174. 
175,  176 


Float  ing  k'idncy  -  -c(»n1  iiiiicil 

correction  of,  178 

corset  support  of,  178 

Dietl  's  crisis  in,  176 

Diculafoy  on,  171 

effect  upon  patient's  health, 
186,  187 

Hedges  on,  170 

Hunner  on,  170.  171 

kidney  belt  for,  178 

Lepine  on,  171 

mental  and  nervous  disorders 
with,  172 

of  questionable  etiology,  186 

peristaltic  action  of  ureter  in, 
187 

toxemia  from,  172 

varieties  of,  183.  184 
Floor,  pelvic  (see  Pelvic  floor) 
Fossa,  ischiorectal.  21 

Gonorrhea 

contraindication  to  operation, 

150,  151 
maculae  of,  40 

sterility  of  infected  tubes,  151 
treatment  for,  70 
Graves's  operation  for  evstocele.  129. 
130 

Ilaynes  on  pelvic  fasciae.  13 
Hegar  perineorrhaphy,  106.  108, 
109,  110 

advantages  of,  111.  116,  118 

denudation  for.  111 

landmarks  for,  110 
Hemorrhage,  post-operative 

control  of,  145,  146 

delayed,  146 

infection  as  cause.  146 

prevention  of.  146 
Hemorrhoids.  104 
Hexamethylenamine.  168 

Ichthyol.  71 
Injury  to  cervix 

amputation  for.  90.  93.  94.  95 

causation  of,  38 

effect  of  pessary  upon.  62.  63 

healing  of.  38 


194 


THE  GYNECOLOGY  OF  OBSTETRICS 


Injury  to  cervix — continued 

immediate  repair,  38 

miscarriage  due  to,  38 

physiological,  37 

prevention  of,  38,  39 

scar-tissue  formation  in,  62 

symptoms,  66,  68 

trachelorrhaphy,  90,  91,  92 
Injury  to  perineum 

character  of,  77 

child's  head  in  relation  to,  37 

diagnosis  of  degree  of,  77,  78 

episiotomy  in  relation  to,  34,  35 

prevention  of,  35 

relation  to  sterilitj''  and  mis- 
carriage, 156 

repair  of,  75,  76 

secondary  repair  of,  105  (see 
Perineorrliaphy  ) 
Interposition  operation  for  cvstocele, 

129 
Intra-abdominal  pressure 

definition  of,  27,  29 

forces  within  abdomen,  28 
Iodine,  use  of,  71,  139 

Kidney  belt,  178 

Kidney  ptosis  (see  Floating  kidney) 

Knee-chest  position,  104 

Leucorrhea,  66,  68,  69,  102 
Levator  ani 

attachments  of,  11,  13,  14 

function  of,  125 

in  male,  115,  116 

union  of,  118 

in  relation  to  relaxed  outlet,  98, 

104,  114 
in  relation  to  prolapse  of 

vagina,  14 
segments  of,  13,  14,  15,  115,  122, 

125 
variations  (Piersol),  15,  115 

Menorrhagia,  66,  68 

Menstrual  cycle    (Hitschmann  and 

Adler),  52,  53 
Menstruation 

in  relation  to  operation,  150 

irregular,  66,  102,  150 

recurrence  of,  150 
Metrorrhagia,  66,  68 


Miscarriage 

case  histor}^  of,  159 
due  to  cervical  tear,  38,  160 
effect  of  amputation,  91 
Emmet  operation  for,  158 
Pozzi's  operation  in  relation  to, 

152 
relaxed  vaginal  outlet  in  rela- 
tion to,  158 
syphilis  as  cause,  156 
]Muscles  of  pelvis 
coccygeus,  14 
constrictor  vaginae,  or  deep 

sphincter,  18 
erector  clitoridis,  18 
Guthrie 's,  or  compressor  ure- 
thra, 18 
levator  ani,  13,  14,  15,  115,  122 

(see  Levator  ani) 
sphincter  ani,.  17,  78,  80 
sphincter  ani,  repair  of,  79,  80, 

109 
sphincter  vaginae,  or  bulbo- 

cavernosi,  17,  18,  106 
transversus  perinei,  deep,  17, 

18,  106 
transversus  perinei,  superficial, 
17,  18.  106 

Pathology  of  cervix 

carcinoma,  45,  46,  47 
chancre,  43 
chancroid,  40,  43 
chorioepithelioma,  51 
chronic  congestions,  51,  53,  54, 

69 
cystic  cervix,  41 
diphtheroid  infection,  41 
effect  of  relaxed  vaginal  outlet 

upon,  64 
endocervicitis,  53  • 
epithelioma,  45 

erosions,  59,  60,  92  (see Erosion) 
fibroids,  51 
gonorrhea,  40 
infections,  40 
polyp,  66 
sarcoma,  51 

syphilis,  40,  43,  41,  70,  142 
treatment  of,  69 
tuberculosis,  41,  42,  43 


INDEX 


1!).") 


I*('l\ic  (li;i|)tii';ii;iii 

iiiial  i'asciii  of,  20 

fMscinc  of.  11.  20 

riitict  ioti  of.  22.  2S 

rcpiiir  of.   104 

rcsiil!  of  iiijiifv  1o'.  2:5.  2."),  29, 

!)7.  !)8 
structiu'e  of.  1 1.  22 
tearing'  of.   hciicalh   ("(Miti'.-il   t;'>i- 
(lon.  35 

I'clvic  Hoor 

( 'olios 's  fascia,  17,  18 

function  of,  22 

muscles  in  relation  to  fascia.  16 

repair  of,  10-4 

result  of  injury  to,  23 

structure  of,  15,  16,  22 

triangular  ligament,  18 

Perineal  tears 

character  of,  36 
diagnosis  of,  36 
direction  of,  35,  36 
how  produced,  37 
repair  of,  74  (see  Perineor- 
rliaphij) 

Perineorrhaphy  ( immediate ) 
best  time  for,  75,  76 
cause  of  poor  results  from,  79 
delayed,  75 
difficulties  of,  74 
methods  for,  77.  78 
sphincter-ani  repair,  78,  80,  81 
tearing  out  of  sutures,  75 
use  of  continuous  suture,  77, 
78,  79,  80,  81 

Perineorrha phy   ( secondary ) 

demonstration  of  correct,  99 
Emmet,  106,  109,  112,  113,  117, 

126 
essentials  for  perfect,  117 
flap  method  of,  116.  117 
Hall's,  113 
Hegar's.  106,  108,  109,  110,  111, 

116.  118 
hemorrhage  following,  145 
landmarks  for.  106.  108 
^Morris's  mediflcation.  113 
objections  to  triangular  denuda- 
tion. 117 


I  'criiicorrliii  |)liy  (  scc(»n(l;ii-y  )  — -i-oiil . 

pool'    lllliiill     ol'    IMIICOIIS    lllclll- 

hi'anr.    l;').") 
preparation   for.  138,  139 
prognosis  in,  141 
rectal  flstula  in  relation  to.  121 
scissors  puncture  in.  114,  116 
Somers's  sutiu'c,  119,  120 
stretching  out  of  scars  after.  1  -12 
sutures   used   in.   104,   118 
Tait's,  104,  107.  108 
Perineum 

episiotoniy  on.  32 
function  of  intact.  25 
Ilartnuuni  on  injury  of,  35 
posture  of  mother  in  preventing 

injury  to,  31 
prevention  of  injury  to.  31 
results  of  injury  to,  25 
vaginal  redundancv,   effect   up- 
on, 143 
Varnier's  method  for  prevent- 
ing injury  to,  31 
Positions  for  examination,  104 
"Posterior  commissure,"  113 
Post-operative  treatment,  134,  136, 
138 
catheterization,  137 
getting  up,  138 
laxatives,  137 

of  complete  perineorrhaphy,  137 
removal  of  sutures,  138 
tying  of  knees,  138 
Pozzi's  operation  for  sterility 
indications  for,  153 
poor  results  following,  152 
scar-tissue  resulting  from,  153 
Procidentia,  25,  26,  27,  122 
Ptosis  of  bladder 

case  histories,  166,  167 
cause  of  chronic  cystitis,  165 
diagnosis  of,  168,  169 
pessary  treatment  for,  169 
prognosis  in.  169 

Quantitative  determination  of  germs 
in  urine.  177 

Rectal  fistula.  80.  121 


196 


THE  GYNECOLOGY  OF  OBSTETRICS 


Rectocele 

as  hernia,  23 

fasciae  in,  10,  21 

in  relation  to  relaxed  outlet,  97, 

103,  117 
not  severe  with  procidentia,  27 
production  of,  23 

Rectovesical  fascia,  12 

Rectum 

direction  of,  20 
introduction  of  speculum,  20 
relations  of,  20 

Relative  sterility,  156,  157 

Relaxed  vaginal  outlet 

air  in  vagina  with,  104 
backache  in  relation  to,  102 
case  histories  of,  100,  101 
cause  of  eye-strain,  101 
cause  of  miscarriage,  156,  157, 

158 
cause  of  sick  headache,  100 
cystocele  as  diagnostic  of,  97 
demonstration  of,  97,  98 
demonstration  of  correct 

repair,  98,  99 
development  progressive,  32 
diagnosis  of,  97,  99 
effect  of  gravity  in,  27 
effect  on  nervous  system,  99,  100 
episiotomy  in  relation  to,  34 
excessive  vaginal  redundancy, 

143 
external  appearance  of,  97 
gravity  a  factor  in,  27 
ideals  of  correct  repair,  105 
intra-abdominal  pressure  in,  29, 

30 
rectocele  as  diagnostic  of,  97 
recurrence  of  symptoms  of,  144 
symptoms  of,  99,  102,  103 

Repair  of  cervix  (see  Traclielor- 
rhaphy) 

Repair  of  cystocele 
Graves's,  129,  130 
methods  of  denudation,  131 
methods  of  operation,  127,  128, 

129,  130 
Sanger's,  130 
White's,  124,  131 


Reynolds  operation  for  sterility  and 

dysmenorrhea,  153,  154 
Residual  urine,  169 
Retentive  power  of  abdomen,  27 
Rodman  on  cancer  of  cervix,  45,  50 
Rosenow's  germ  theory,  42 

Separation  of  recti  muscles,  39 
Silver  nitrate,  71 
Sims 's  discission  operation,  153 
Sims 's  position,  value  of,  104 
Skene's  anterior  incision  operation, 

154 
Sphincter  ani  repair 

immediate  operation,  78,  80,  81 
secondary  operations,  109 
after  treatment  of,  137 
Stem-pessary  contraindications,   156 
Sterile  urine,  162,  163,  169,  170,  179, 
180,  184   (see  Bacteriological 
examination  of  urine) 
Sterility  of  infected  tubes,  151 

Sterility 

case  history  of,  160 
causes  of,  152,  158 
Dudley-Reynolds  operation  for, 

153' 
due  to  cervical  tear,  38,  160 
due  to  tubal  pathology,  156 
Emmet  operation  for,  157 
Pozzi's  operation  for,  152 
relation  to  cervical  amputation, 

91 
relative  sterility,  156,  157 
statistics  of  cure,  154,  155 
Sutures,  effect  of  absorbable,  69 
Syphilis  of  cervix 

appearance  of  cervix  in,  142, 

143 
chancre,  43 
cause  of  failure  of  operation. 

142 
cause  of  miscarriage,  156 
diagnosis  of,  143 
secondaries,  43 
tertiaries,  43 
treatment  of.  70 


INDEX 


197 


Tait \s  pcriiicdfrlijipliy 

advaii1;i.u('s  oW  1 1 1 

conipli'tc,    lOS 

iiu'omph'te,  104,   107 
Tanii)()ii  tivatineiit,  (i!).  70.  71.  148 

(•oniposition  of  tampon,  72 

vlriigs  used  in,  71,  72 

prtjprietary  tampons,  72 

removal  of  tampon.  72 
Trac'liclori'liaphy 

adhesion  oT  lips  in.  147.  148, 
149 

after-treatment  of  patient.  134. 
136,  138 

determination  of  denudation,  92 

tiiscliarge  following,  136 

etfect  of  pessary  upon,  63 

Emmet,  90,  91,'  92 

hemorrhaoe  following,  145,  146 

immediate  repair,  74 

interference  with  drainage 
after,  147 

method,  74 

preparation  of  patient,  138,  139 

prognosis  in.  141 

sutures  in,  74 

suture  insertion  in,  93 
Treatment  in  gynecology  (see  Tam- 
pon) 

applications  to  cervical  canal, 
70 

dangers  from  applications  to 
cervical  canal,  71 
Triangular  ligament,  18,  125 
Tuberculosis  of  cervix,  42,  43 

diagnosis  of,  43 

Unilateral  nephritis,   171,   173,   174, 
182.  184 
ease  histories  of,  172,  173,  174 
cystoscopic  findings  in,  184 
pathology  of,  174,  182 
results  of  operation  in,  185 
symptoms  and  findings  in,  182 
ureter  catheterization,  177 

Ureters 

course  of,  9 
palpation  of.  10 
relations.  9,  24 


Urethra 

attach iiienls  of,  20,  125 

catheterization  of,  20,  135,  137 

cleansing  for  catheterization, 
135 

gonorrhea  of,  41 

landmarks  for  finding  orifice  of, 
19 

Littre's  follicles,  41 

location  of,  19 

severance  of  attachments,  127 
Urethrocele,  127 
Urine 

casts,  diagnostic  value  of,  162 

collecting  specimens,  168 

culture  of,  164 

determination  of  residual,  169 

fermentation  of,  165 

germicidal  power  of,  164,  181 

quantitative  determination  of 
germs  in,  164,  179 

residual,  165,  169 

sterility  of,  162,  163,  179,  180 
(see  Bacteriological  examina- 
tion) 

value  of  bacteriological  exami- 
nation of,  181 
Uterus 

anteflexion  of,  3 

applications  to,  88 

circulation  of,  55 

congestion  of.  55 

effect  of  relaxed  outlet  upon 
position  of,  25 

endometritis  in,  53,  84 

irrigation  of,  88 

ligaments  of,  24 

mucous  membrane  of.  56 

OS  (external)  of,  3 

OS.  direction  of.  3 

OS  (internal)  of.  3 

pessarv  for  abnormal  position 
of.  62 

position  of.  25 

prolapse  of.  26.  27 

retroversion  of.  25 

retroversion  not  a  cause  of 
procidentia  of,  25 

support  of,  128 


198 


THE  GYNECOLOGY  OF  OBSTETRICS 


Vagina 

blood  supply  to,  11 

direction  of,  10 

fasciae  of,  10 

injuries  of,  2 

lymphatics  of,  11 

mucous  membrane  of,  10,  11 

nerves  of,  11 

relation  to  other  organs,  10 

resistance  to  infection  of,  189 

structure  of,  2,  10,  11 
Vaginal-wall  denudation,  143 


Vaginitis,  senile,  148,  149 

Vomiting 

post-operative,  134 
treatment  of,  134,  135 

"  White  line,"  12,  123,  125,  126, 132 

' '  White  line  ' '  in  relation  to  cvsto- 
cele,  123,  126,  129 

White's  cystocele  operation,  124, 
131 

White's  theory  of  cystocele  causa- 
tion, 124,  131 


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Tnstnictor  in  Diseases  of  Children  in  the  New  York  Post-Graduate  Medical  School;  As- 
sistant Attending  Physician  to  the  Babies'  Wards  in  the  New  York  Post-Graduate 
Hospital;  Chief  of  Clinic  in  the  Post-Graduate  Dispensary  for  Children;  Fellow  of 
the  New  York  Academy  of  Medicine. 

Cloth,  S35  pp.,  index,  Izmo,  $1.00  net 

Dr.  Dennett  is  a  Avell-known  physician  in  New^  York  City  and  is  also  a 
wa-iter  of  reputation.  AVhat  he  has  to  say,  therefore,  on  such  subjects  as 
appetite,  clothing,  the  bath,  exercise,  discipline,  nervousness,  fever,  the 
throat,  the  teeth,  milk,  and  mixing  and  care  of  the  food,  and  food  for  travel- 
ing is  certain  to  secure  wide  attention.  Physicians  can  well  recommend  this 
l)ook  to  mothers. 


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RESEARCHES  ON  RHEUMATISM 

By  F.  J.  POYNTON,  M.  D.,  Lond., 

Vice-Dean  of  University  College  Hospital  Medical  School,  Senior  Physician  to  Out- 
patients at  University  College  Hospital,  London,  etc.,  and 

ALEXANDER  PAINE,  M.  D.,  Lond.,  D.  P.  H.,  Eng., 
Director  of  the  Cancer  Eesearch  Institute,  London 

^61  pp.,  index,  with  frontispiece  in  color  and  106  ill.,  8vo.  $5.00  net 

This  collection  of  papers  is  the  result  of  fifteen  years '  work  by  these  two 
noted  authorities,  who  are  well  known  to  the  American  profession  for  their 
researches  in  this  subject.  This  product  of  their  joint  authorship  makes  a 
remarkable  history  of  achievement  and  steady  advance  in  our  knowledge, 
and  it  is  needless  to  say  that  the  literary  quality  is  of  the  highest.  The  book 
unquestionably  gives  the  most  recent  and  authentic  presentation  of  a  very 
important  group  of  diseases,  and  at  the  conclusion  of  the  volume  the  bearing 
of  these  investigations  upon  clinical  medicine  and  public  health  is  con- 
sidered in  a  special  article.  Etiology,  pathology,  symptomology,  diagnosis, 
prognosis,  treatment  and  prevention  are  summarized  at  the  end,  so  that  this 
work  stands  as  a  complete  treatise  on  the  subject.  The  illustrations  have 
been  chosen  with  the  intention  of  demonstrating  the  intimate  processes  of 
rheumatism  in  the  body,  and  to  act  as  a  pictorial  guide  to  the  main  conclu- 
sions. Their  workmanship  is  so  perfect  that  they  are  almost  equal  to  the 
microscope  slide  itself. 

ON  DISEASES  OF  THE  RECTUM  AND  ANUS 

By  HAREISOX  CRIPPS,  F.  E.  C.  S.. 

Consulting  Surgeon,  St.  Bartholonie"^v  's  Hospital 

Fourth  Edition,  including  the  Sixth  Edition  of  the  Jacksonian  Prize  Essay  on  Cancer, 
and  the  Opening  Address  on  the  Surgical  Treatment  of  Eectal  Cancer,  delivered  at 
the  Annual  Meeting  of  the  British  Medical  Association,  Liverpool,  1912. 

Illustrated.  Cloth,  8vo.  $3.S5  net 

Dr.  Cripps,  the  author  of  this  important  monograph,  is  well  known  in 
this  country  as  an  authority  on  these  subjects  and  as  a  wide,  contributor  to 
many  American  medical  magazines.  The  clinical  cases  recorded  in  this 
monograph  are  largely  drawn  from  his  notes  made  in  the  Registers  of  St. 
Bartholomew's  Hospital,  and  the  pathological  observations  have  been  veri- 
fied by  post-mortem  or  microscopic  investigation. 


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FEEBIJvMlNDEDNESS:  ITS  CAUSES  AND 
CONSEQUENCES 

IJv  HENRY  II.  (JODDARD, 

Director  of  the  Kosearcli  Laboratory  of  the  Training  Seliool  at  Vineland,  N.  J., 
for  J<"'eel)le-J\'Iin(le(l  Uirls  and  Boys 

ClolJi.  Si-o,  r>'.):)  pp.,  index,  $4.00  net 

This  work  is  a  I't'inarkable  record  of  tlie  results  ol'  inaii,>'  years 'experience 
tind  study  of  a  class  of  persons  in  whose  condition  great  popular  interest 
has  been  aroused  with  a  view  to  ])ettering'  their  condition  and  to  grasp  its 
fundamental  causes. 

It  diit'ers  from  most  of  those  in  the  field  in  that  it  is  what  may  be  termed 
a  source  study.  Instead  of  generalizing  on  the  subject  of  feeble-mindedness, 
presenting  arguments  for  this  theory  and  that  and  concluding  with  vague 
speculations,  Dr.  Goddard  gives  facts.  The  book  is  so  comprehensive  in  scope 
and  the  cases  exhibit  such  a  variety  of  disorders  that  not  infrequently  will 
the  parent,  the  teacher  and  all  who  have  to  do  with  incorrigible,  delinquent 
or  unfortunate  children  encounter  characteristics  similar  to  those  displayed 
by  the  subjects  discussed  by  Dr.  Goddard. 


THE  KALLIKAK  FAMILY 

By  henry  H.  GODDAED 

Illustrated  leith  eliarts  and  half  tones.  Cloth,  8vo,  121  pp.    $1.50  net 

A  genuine  story  of  real  people,  this  book  is  a  study  in  heredity,  the  name 
of  the  family  being,  of  course,  fictitious.  As  director  of  the  Training  School 
at  Vineland,  N.  J.,  Dr.  Goddard  has  long  been  studying  the  cause  of  feeble- 
mindedness, and  he  here  presents  the  results  of  an  investigation  made  of  one 
notorious  family  of  degenerates.  Taking  scientific  observations  as  a  base. 
Dr.  Goddard  has  told  a  story  which  will  be  of  interest  to  students  of  educa- 
tion, medicine  and  sociology,  and,  because  of  its  dramatic  intensity,  to  the 
aeneral  reader. 


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THE  INTERPRETATION  OF  DREAMS 

By  PROPESSOK  SIGMUND  FREUD,  M.  D.,  LL.  D.. 

Formerly  Professor  of  Nervous  and  Mental  Diseases  in  the  University  of  Vienna 

Translated  by  A.  A.  BRILL,  Ph.  B.,  M.  D. 

Chief  of  the  Neurological  Department  Bronx  Hospital  and  Dispensary;  Clinical  Assistant 
in  Psychiatry  and  Neurology,  College  of  Physicians  and  Surgeons,  New  York 

Cloth,  510  PI).,  index,  literary  index,  8vo.  $4.00  net 

The  general  advance  in  the  study  of  abnormal  mental  processes  has  called 
particular  attention  to  the  dream,  whose  riddle  has  been  solved  by  Professor 
Freud,  the  noted  neurologist  at  the  University  of  Vienna,  in  connection  with 
his  study  of  nervous  and  mental  diseases.  Professor  Freud  asserts  that 
dreamis  are  perfect  psychological  mechanisms  and  are  neither  foolish  nor 
useless.  He  found  that  dreams,  when  analyzed  by  his  method,  exposed  the 
most  intimate  recesses  of  personality,  and  that,  in  the  study  of  nervous  and 
mental  diseases,  it  is  mainly  through  dreams  that  the  symptoms  of  the 
disease  can  be  explained  and  cured.  This  epoch-making  book  furnishes  many 
useful  and  interesting  contributions  to  the  study  and  treatment  of  nervous 
and  mental  diseases  and  is  most  valuable  to  physicians  and  psychologists. 


PSYCHOPATHOLOGY  OF  EVERYDAY  LIFE 

By  professor  SIGMUND  FREUD,  M.  D. 
Translated  by  A.  A.  BRILL,  M.D. 

Cloth,  demy  8vo,  341  pp.,  index,  $3.50  net 

This  book,  which  is  largely  concerned  with  psychological  causes  of  those 
slight  lapses  of  tongue  and  pen  and  memory  to  which  every  one  is  subject,  is 
perhaps,  of  all  Freud's  books,  the  best  adapted  for  the  general  reader  in 
addition  to  the  scientist.  It  sheds  a  flood  of  light  on  many  phenomena  which 
most  people  are  apt  to  regard  as  insignificant,  but  which  are  really  full  of 
meaning  for  the  student  of  the  inner  life. 


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